Vital Statistics

Name of Deceased (Decedent):
Deceased (Decedent) Legal Address (include apt. number, st, city, state, zipcode):
Date of Birth:
Place of Birth (City, State or Country)
Date of Death: (Age):
Place of Death: (City): (State): (County):
Hospital or Nursing Home or Residence where person Died:
Social Security Number:
Estimated weight (lbs.) of Decedent [Numbers Only, No Letters!]:
Occupation: (Do not enter “Retired”)
Type of Industry:
Highest Level of Education:
Gender: Male Female
Veteran: Branch of Service:
Name of Spouse: (Including Maiden Name)
Marital Status: (Never Married, married, divorced, widow etc)
If legally married, spouse is next of kin and must sign.
Hispanic or non-Hispanic:
Race as defined by US census: White, Black or African American, other- Specify
Father’s Name: (First and Last Name)
Mother's Name: (First and Last include Maiden Name)
Number of Death Certificates:
Medical examiner case number (if applicable)
Next of Kin: Relationship:
Next of Kin Legal Address (include apt. number, st, city, state, zipcode):
Home#: Cell Phone:
Email:

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