New Jersey Department of Health

PO Box 358

Trenton, NJ 08625-0358

COMMUNICABLE DISEASES ALERT

SECTION I - INSTRUCTIONS

The following is a list of contagious, infection or communicable diseases developed in accordance with the provisions of P.L. 1988, C. 125 (N.J.S.A. 26:6-8.2). Funeral directors must be notified in writing if the deceased individual had any of these diseases at the time of death.

Such notification shall be accomplished by placing this form with the remains and forwarding a copy of same to the funeral director. The body shall not be released until this form is completed and placed with the remains.

-Human Immunodeficiency Virus	-Smallpox

Infections including AIDS	-Syphilis-Primary and

(Acquired Immune Deficiency	Secondary (Untreated)

Syndrome)	-Toxoplasmosis Disseminated (Untreated)

-Anthrax	-Tuberculosis (Untreated)

-Creutzfeldt-Jakob Disease	-Tularemia

-Viral Hepatitis B	-Typhoid Fever (Untreated)

-Malaria (Untreated)	-Viral Hemorrhagic Fevers

-Meningococcal Disease (Untreated)	(Contact State Health

-Plague (Untreated)	Department Immediately)

-Q Fever (Untreated)	-Yellow Fever (First 5 Days of Infection)

-Rabies

Complete Section II if the deceased had one or more of the above diseases.

SECTION II
Name of Deceased

Date of Death

Name of Health Care Facility

Name of Funeral Director

I am the attending physician, registered professional nurse or state or county medical examiner who made the determination and pronouncement of death and I have determined or I have knowledge that the above-named individual suffered from one of the communicable diseases listed in Section I above at the time of his/her death.

All persons performing or assisting in post‑mortem procedures should wear gloves, masks, protective eyewear, gowns and waterproof aprons. Instruments and surfaces contaminated during post-mortem procedures should be decontaminated with an appropriate chemical germicide.
Name of Pronouncer (Print)

Signature	Date

Distribution: Original - Funeral Director

Copy - Health Care Facility

Copy - Attach to Remains

LCS-4

JUL 12

COMMUNICABLE DISEASES ALERT, LCS-4

LCS-4, Communicable Diseases Alert, contagious diseases

Elaine White

2001-05-24

ewhite

NJDOH