Vital Information Form
LOVED ONE'S FULL NAME (First, Middle, Last)
First Name, Middle Name
Last Name
Maiden Name
Sex
Please Select
Male
Female
Date of Death
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Race
Hispanic Origin?
If yes, specify
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
S.S.N.
U.S. Armed Forces?
If yes, branch?
Place of birth
City, State
Marital Status
Please Select
Never Married
Married
Divorced
Widowed
Surviving Spouse
If wife, give Full Name)
Decedent's Education
Please Select
8th. grade or less
9th. - 12th. grade, no diploma
High school graduate or GED Completed
Some college, no degree
Associate degree (e.g. AA, AS)
Bachelor's Degree (e.g. BA, AB, BS)
Master's degree (e.g. MS. MEng, EEd, MSW, MBA)
Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)
Unknown
Check the highest degree level.
Usual Occupation / Job
Title
Industry / Business
Deceased Residence
Street Address & Apt. #
Deceased Residence
City, State, Zip Code, County.
Inside city limits
Please Select
Yes
No
Father's Full Name
First, Middle, Last
Mother's Full Name (including maiden name)
First, Middle, Last, Maiden
Informant's Full Name
First, Middle, Last
Informant's Relation to Decedent
Informant's Address
Informant's Phone Number
Informant's Email address
Method of Disposition
Please Select
Burial
Cremation
Name of Cemetery & City
Submit
Should be Empty: