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New Jersey Division of Fire Safety
Office of the State Fire Marshal - Fire Fatality Report Form
Date of Incident:
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+
Alarm Time (24Hr):
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Municipality:
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Incident Address:
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Zip Code:
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Fire Department Name:
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FDID:
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Please check this box if property was an illegal Residential Conversion
NFIRS Participant: (Check One)
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Yes
No
Name
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Age:
*
Gender:
*
Affiliation:
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Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Cause of Fire:
*
Room of Origin:
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Type of Occupancy
*
Detector Operate: (Check One)
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Yes
No
Unknown
Reporting Agency:
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Name: (Person Completing Form)
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Phone:
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Remarks:
Please enter e-mail address below; a copy of this form will be sent after you have submitted the report.
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