Vital Statistics Form

Vital Statistic Information
This form will be used to complete the death certificate. All required items are identified with an asterisk. If you do not have the complete information, please type unknown in the field and we will get the information at a later time.

Name*
FirstLast
Middle name or initial *
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Is address inside of city limits?*
Yes
No
Date of death (mm//dd/yyyy)*

Place of death*
Date of birth (mm/dd/yyyy)

Place of Birth*
Age
Social Security Number*
Education (Highest Level Completed)*
Occupation (Primary occupation during working years)*
Type of Industry (Sales, Medical, Engineering, Construction, Etc.)*
Was the deceased ever in U.S. Armed Forces?*
Yes
No
Marital Status at time of death*
Married
Widowed
Divorced
Never Married
Married, but seperated
Unknown
Name of Spouse, if married (If wife, list maiden name)*
FirstLast
Father's Name*
FirstLast
Mother's Maiden Name*
FirstLast
Ancestry*
English, Irish, French, German, etc.
Was deceased of hispanic origin?*
No, not Spanish/Hispanic/Latino
Yes, Mexican/Mexican American/Latino
Yes, Puerto Rican
Yes, Cuban
Yes, Central American
Yes, South American
Yes, other
Unknown
Method of Disposition*
Burial
Cremation
Entombment (Mausoleum)
Anatomical Donation
Name of Cemetery
Name of responsible party (Informant)*
FirstLast
Address of responsible party (Informant)*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Relationship to deceased*
Phone number of responsible party*
Alternate phone number
Email of responsible party*