Burial Forms Website p 1

Certificate of Death Worksheet
1. NAME OF DECEDENT --- FIRST
2. MIDDLE
3. LAST (Family)
AKA. --- (FIRST MIDDLE AND LAST)
4. DATE OF BIRTH mm/dd/ccyy

MonthDayYear
Date
5. AGE Yrs.
6. SEX
7. DATE OF DEATH mm/dd/ccyy (may be left blank)

MonthDayYear
Date
8. HOUR (24 HOURS) (may be left blank)
9. BIRTH STATE/FOREIGN COUNTRY
10. SOCIAL SECURITY NUMBER
11. EVER IN U.S. ARMED FORCES?

YESNOUNK
12. MARITAL STATUS (Married, Widowed, Divorced, Never Married, SRDP)
13. EDUCATION --- Highest Level/Degree
14/15. WAS DECEDENT SPANISH/HISPANIC/LATINO?

YES
IF YES, SPECIFIC TYPE
14/15. WAS DECEDENT SPANISH/HISPANIC/LATINO?

NO
16. DECEDENT’S RACE --- Up to 3 races may be listed
17. USUAL OCCUPATION — (before retirement)
18. KIND OF BUSINESS OR INDUSTRY
19. YEARS IN OCCUPATION (or year started if still working)
20. DECEDENT’S RESIDENCE (Street and number or location)
21. CITY
22. COUNTY/PROVINCE
23. ZIP CODE
24. YEARS IN COUNTY (or year arrived)
25. STATE/FOREIGN COUNTRY
26. INFORMANT’S NAME, RELATIONSHIP
27. INFORMANT’S MAILING ADDRESS (Street and number or rural route number, city or town, state, ZIP)
28. NAME OF SURVIVING SPOUSE --- FIRST (IF MARRIED)
29. MIDDLE (IF APPLICABLE)
30. LAST (Maiden Name, if female) (IF APPLICABLE)
31. NAME OF FATHER --- FIRST
32. MIDDLE (IF APPLICABLE)
33. LAST
34. BIRTH STATE
35. NAME OF MOTHER --- FIRST
35. MIDDLE (IF APPLICABLE)
37. LAST (Maiden Name, if female)
38. BIRTH STATE
39. DISPOSITION DATE mm/dd/ccyy (IF KNOWN)

MonthDayYear
Date
40. PLACE OF FINAL DISPOSITION (IF KNOWN)
41. TYPE OF DISPOSITION(S) (I.E. CREMATION/BURIAL)
42. EMBALMED (YES OR NO)
CONFIRMATION OF ACCURACY
I acknowledge that I am responsible for the information on this form. I have reviewed it for accuracy and it is correct.
I authorize Welch-Ryce Haider Funeral Chapels to complete the Death Certicate for the above-named as soon as possible using the information I have certied as correct.
If any of the above information proves to be incorrect, I authorize Welch-Ryce-Haider Funeral Chapels to amend the Death Certicate, at my request, with the correct information I will provide.
If I request replacement certied copies of the amended Death Certicate, I authorize Welch-Ryce-Haider Funeral Chapels to order them at my expense.
SIGNATURE
Signature

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DATE

MonthDayYear
Date
Place of Death
County
Address
City
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Certificate of Death Worksheet

CONFIRMATION OF ACCURACY

SIGNATURE