Dee Funeral Home & Cremation Services
Caring for families since 1868
Vital Statistics Information for death certificate completion
Full Legal Name (Maiden)
Example: Mary Anne Smith (Parker)
Sex
Social Security Number
Date of Birth
/
Month
/
Day
Year
Date
Birthplace
Marital Status
Residence
Full Address
Veteran Status (yes/no)
Veteran Info
Please email veteran discharge documents if applicable
Last Spouse, include maiden name if applicable
Example: Mary Anne Smith (Parker)
Father
Father’s birthplace
For US, list only State. Outside US, list country. (Canada, please list province.)
Mother (Maiden)
Example: Mary Anne Smith (Parker)
Mother’s birthplace
For US, list only State. Outside US, list country. (Canada, please list province.)
Ethnicity/Ancestry
Example: American, Irish, German
Race
Example: White, Asian, Black
Last Occupation
Example: Registered Nurse
Last Industry worked in
Example: Healthcare
Education: (highest grade or degree)
Examples: 8th Grade, High School, Some College, Assoc., Bachelors, Masters, Doctorate or Professional degree.
Informant name
Informant relationship to deceased
Informant address
Informant phone/email
Method of disposition (burial or cremation)
Place of disposition
Notes/other information
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