EOHHS-DDS

REQUESTOR INFORMATION:

Name(Required)

First Last

Phone(Required)

Email(Required)

Name of Academic Research Institution(Required)

Website of Academic Research Institution(Required)

Description of Research(Required)

Deceased Resident Facility Information:

Researcher Has Information Showing Date of Death of Specific Former Resident.

Researcher Does Not Have Information Showing Date of Death.

Attach list showing (1) Name of deceased resident, (2) DDS facility, and (3) general timeframe when the individual was admitted to the DDS facility, along with documents showing the date of death (e.g., individual's death certificate or obituary).(Required)

Drop files here or

Max. file size: 20 MB, Max. files: 1.

DDS can only provide responsive resident records if DDS has documents showing that the former DDS resident is deceased more that 50 years (i.e., DDS possesses documents that verify the date a resident died or DDS received a death certificate after discharge).

Requester Certification(Required)

I certify that the information above and any attachments is complete and accurate under the pains and penalties of perjury (type First & Last name).

Date(Required)