Death Certificate Worksheet

Death Certificate Worksheet
Deceased Full Name
Sex
Age
SS#
If not comfortable submitting this online please call it in.
Date of Death

MonthDayYear
Date
Time of Death
Place of Death
Facility of Death
Date of Birth

MonthDayYear
Date
Birthplace
City, County, State, Country
Marital Status

Never MarriedMarriedWidowedDivorcedMarried/Separated Unknown
Spouse (full maiden name)
When Married
Where
If deceased, date of death

MonthDayYear
Date
Physician
Occupation (before retirement)
Type of Industry
Decedent's Address
City
County
State
Zip
Father's full name
Mother's full name with maiden
Informant
Relationship
Street Address
City, State, Zip
Phone
Email
example@example.com
Decedent Education:
Education

8th Grade or less9-12th Grade, no diplomaHigh School Graduate/GED completedSome College Credit, no DegreeAssociate DegreeBachelor’s DegreeMaster’s DegreeDoctorateNoneUnknown
Decedents Nationality
Was decedent in the U.S. armed forces?
Place

World War I – Apr 6, 1917 to Nov 11, 1918World War II – Dec 7, 1941 to Dec 31, 1946Korean War – Jun 27, 1950 to Jan 31, 1955Gulf War – August 2, 1990 to OtherVietnam Era – Aug 5, 1964 to May 7, 1975
Service Information--A copy of the discharge and service papers is required to receive military honors, veteran’s flag, or headstone
Date of entry into service

MonthDayYear
Date
Place
Serial Number
Grade, Rank, Rating
Organization & Branch
Date separated from service

MonthDayYear
Date
Should be Empty: