Notice of Death

Please complete this form to report the death of a Pasco County Schools employee, retiree, or covered dependent.

Employee Name Employee Name First Last
Employee ID#
Name of Deceased Name of Deceased First Last
Date of Death Date of Death / MM / DD YYYY
Deceased relationship to Pasco County Schools

Please use the drop down menu to tell us whether the deceased was an active or retired employee or dependent spouse or child.
Was the deceased married?

Was the deceased married? Yes No
If yes, enter spouse's name If yes, enter spouse's name First Last
Date of Marriage Date of Marriage / MM / DD YYYY
Are there dependent children under age 25?

Are there dependent children under age 25? Yes No
If yes, enter child(s) name and date of birth if known.
Person to Contact
Name Name First Last
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Relationship to Deceased
Have you been in contact with the family?

Have you been in contact with the family? Yes No
Death Reported By
Name Name First Last
Phone Phone - ### - ### ####
Relationship to Deceased
Form Completed By:
Name Name First Last
Phone Phone - ### - ### ####
Email