Vital Statistics

Vital Statistics

This information will be used to complete the Death Certificate as required by the State of Indiana. If any information about the deceased is unknown, please type "UNKNOWN" in the corresponding box. Desktop users: TAB through boxes. Using the Enter key will result in immediate submission.
Which location of Cruz Family Funeral Home are you utilizing?
1. Decedent's Legal Name: (First, Middle, and Last)
Please add any suffixes the deceased used, such as Jr., Sr. III, etc.
1a. Maiden name:
(if female)
1b. Did the Decedent have a preferred name
Example: Robert referred to himself as "Rob" or "Bob"
2. Gender:
3.Decedent's Time of Death:
am/pm
4. Decedent's date of Death:
(Month/Day/Year)
5. Decedent's Social Security Number:
6. Decedent's Age:
7.Decedent's Date of Birth:
(Month/Day/Year)
8. Decedent's Birthplace:
(City and State or Foreign Country)
9. Did the Decedent serve in the US Armed Forces:
9a. Which branch of service:
9b. Date and Era of Service:
Example: 1962-1974, Vietnam War
10. If the death occured in a Hospital, did the death occur as an :
10a. If the death occurred OUTSIDE of a Hospital, did the death occur at:
11. Facility Name:
If "Other" was checked in box 10a, please give full street address)
12. City or Town, State and Zip Code of place of Death:
(example: Mishawaka, Indiana 46544)
13. County of Death:
14. Marital Status at time of Death:
15. Surviving Spouse's Name
(First, Middle, Last name)
15a. Spouse's maiden name:
(If applicable)
16. Decedent's usual occupation:
(General categories such as "Homemaker, Truck Driver, Laborer, Management, Salesman, etc. are acceptable ** DO NOT USE "RETIRED")
17. Description of business, or industry in which the Decedent worked:
(General categories such as "Own Home, Factory, Insurance Sales, Transportation, etc. are acceptable)
17a. Retired?:
17b. Name of Employer and number of years worked
Example: Forest River, Middlebury, 32 years
18. Deceased's State of Residence:
(Example: Indiana, Michigan, Ohio, etc.)
18a. Deceased's County of Residence:
(Example: St. Joseph, Elkhart, Marshall, etc.)
18b. Deceased's City of Residence:
(Example: Osceola, Mishawaka, South Bend, etc.)
18c. Decedent's Street Address:
(123 Main Street, Avenue, Drive, etc.)
18d. Decedent's Lot or Apartment Number:
(List Lot or Apartment number if applicable)
18e. Decedent's Zip Code:
18f. Does the Decedent live inside the City Limits? (Note: addresses with 2, 3 or 4 numbers are inside the City Limits, 5 number addresses are outside the City Limits)
19. What is the Decedent's highest grade of education?
20. Is the Decedent of Hispanic origin: (e.g. Spanish/Hispanic/Latino)
20a. If the Decedent is of Hispanic origin, please check the box that best describes the Country of origin:
21. Decedent's race:
22. Father's name
First, Middle, Last, suffix (Jr. Sr., III, etc.)
23. Mother's name
First, Middle, Last (if re-married, list CURRENT legal last name)
23a. Mother's Maiden name
(Mother's last name at birth)
24. Informant's name
(First, Middle, Last) * Informant is defined as the person who verifies the information given above.
24a. Relationship to Decedent:

Other
24b. Informant's mailing address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
24c. Informants Telephone number:
Please enter a valid phone number.Format: (000) 000-0000.
24d. Informant's E-mail address:
example@example.com
Surviving Relatives and Personal Information:

The following information such as surviving members of the family, number of Grandchildren, Great Grandchildren, and siblings will be used to prepare the online obituary that will be published on the Funeral Home's website. The more information you are able to provide about your loved one, the more detailed our Staff can be in preparing a short story of their life.
Spouse

First, and Middle NameLast Name
Date of Marriage:

MonthDayYear
City and State of Marriage:
Name of Church may be listed if desired.
Surviving Children: Name and City of Residence
Please list Child's spouse in parenthesis- EXAMPLE: John (Sally) Smith of Jonesboro, Arkansas
Surviving Siblings: Name and City of Residence
Please list Sibling's spouse in parenthesis- EXAMPLE: John (Sally) Smith of Jonesboro, Arkansas
Surviving Grandchildren:
Grandchildren may be listed as a number (12 Grandchildren) or individually by name EXAMPLE: John (Sally) Smith of Jonesboro, Arkansas
Surviving Great, Great-Great, Great-Great Great Grandchildren, etc.
Great/Great- great grandchildren may be listed as a number (12 Great grandchildren, 6 Great-great grandchildren) or individually by name EXAMPLE: John (Sally) Smith of Jonesboro, Arkansas
Deceased Relatives: Children, Siblings, Grandchildren, etc.
Hobbies and Activities, Memberships, Interests
Example: Deceased was a fan of the Indianapolis Colts. Deceased enjoyed camping. Deceased was a member of XYZ Church for many years...etc.
Provide some words describing your loved one:
Example: Kind, Hardworking, Great sense of humor, Loving, etc.
How many certified copies of the Death Certificate will you require?
* Certified Death Certificates are $15.00 each. A fee of $10.00 will be added to the total if the certificates are to be mailed via certified mail.
Will the death certificates be:
Would you like our staff to prepare an obituary?
If your family has chosen an obituary, please upload photo of the deceased here:

JPG, TIFF, PNG format. Cruz Family Funeral Home reserves the right to edit/modify photo to meet the guidelines of our website/newspaper guidelines.
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My loved one wishes for:

Other
Does the decedent own Cemetery property?
If yes, which Cemetery?
Example: Olive Cemetery, Fairview Cemetery, Etc.
DISCLAIMER AND TERMS OF ONLINE FORM SUBMISSION
CRUZ FAMILY FUNERAL HOME

Please be advised that the online submission of documents and forms through this platform is offered solely as a convenience to the public. Cruz Family Funeral Home, including its owners, affiliates, agents, employees, and representatives (hereinafter collectively referred to as “Cruz Family Funeral Home”), shall not be held liable for any errors, omissions, delays, or technical issues that may arise during or as a result of the electronic transmission or processing of said forms.

By electing to submit forms online, you expressly acknowledge and agree to the following terms and conditions:

Limitation of Liability:
Cruz Family Funeral Home shall bear no responsibility for any interruption of service, network failure, system malfunction, or other technical impediment that may result in the delay, failure, or non-receipt of submitted documents.
Responsibility for Content:
You, the submitter, are solely responsible for ensuring the accuracy, truthfulness, and completeness of all information provided. Cruz Family Funeral Home disclaims any liability for consequences resulting from inaccurate, incomplete, or erroneous information submitted through this platform.
Submission Does Not Constitute Receipt:
The act of submitting a form online does not constitute confirmation of its receipt by Cruz Family Funeral Home. You are advised to contact the funeral home directly to verify that your submission has been received and processed.
Security and Assumption of Risk:
While Cruz Family Funeral Home has implemented reasonable security measures to protect the integrity of this submission process. Although the forms are encrypted, it does not and cannot guarantee the absolute security of information transmitted over the Internet. Any and all data, including sensitive personal information, is submitted at your own risk.
Modifications to Terms:
Cruz Family Funeral Home reserves the right to amend, revise, or otherwise update this disclaimer and its terms at any time without prior notice. It is your responsibility to review the disclaimer periodically for any changes.
Identification Requirement:
In order for the submission to be valid and processed, a legible copy of the legal next of kin’s government-issued photo identification must be uploaded concurrently with the completed forms. Additionally, the legal next of kin must provide a valid signature on the forms submitted.

By signing below and proceeding with the online form submission, you affirm that you have read, understood, and accepted all the terms and conditions set forth in this Disclaimer and Terms of Online Form Submission.

If you do not agree to any portion of the foregoing terms, you must refrain from using the online submission platform and contact Cruz Family Funeral Home directly to obtain alternative methods of submission.
Submit Copy of Drivers License or State ID

Please submit a photo of your Drivers License or State issued ID for verification purposes.
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Signature
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Vital Statistics

Surviving Relatives and Personal Information: