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?

Cruz Family Funeral Home, 1109 Lincolnway W. Osceola, IndianaWells and Cruz Family Funeral Home, 507 W. Third St. Mishawaka
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:*

YesNo
9a. Which branch of service:

ArmyNavyAir ForceMarinesCoast GuardSpace Force
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 :*

InpatientIn the Emergency RoomDead upon Arrival
10a. If the death occurred OUTSIDE of a Hospital, did the death occur at:

Hospice FacilityDecedent's HomeNursing Home or Long Term Care FacilityOther
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:*

MarriedMarried but SeparatedDivorcedNever MarriedWidowed
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?:

YesNo
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)

YesNo
19. What is the Decedent's highest grade of education?*

8th Grade or less9-12 Grade - No Diploma or GEDHigh School Graduate or GED recipientSome College, but no degreeAssociate's Degree (AA, AS)Bachelor's Degree (BA, AB, BS)Master's Degree (MA, MS, MEng, MSW, MBA)Doctorate (PhD, EdD) or Professional Degree (MD, DDS, DMV, LLB, JD)
20. Is the Decedent of Hispanic origin: (e.g. Spanish/Hispanic/Latino)*

YesNo
20a. If the Decedent is of Hispanic origin, please check the box that best describes the Country of origin:

Mexican, Mexican American, ChicanoPuerto RicanCubanOther: Spanish/Hispanic/Latino
21. Decedent's race:*

WhiteBlack or African AmericanAmerican Indiana or Alaska NativeAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawaiianGuamanian or ChamorroSamoanOther: Pacific IslanderOther
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:*

HusbandWifeSonDaughterFatherMotherBrotherSisterGrandfatherGrandmotherGrandsonGranddaughterNephewNieceCompanionCaregiverHealthcare Power of AttorneyOther
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.
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:

Mailed to the informant's address via USPSPicked up in person at the Funeral Home
Would you like our staff to prepare an obituary?

Online only on our website (no fee applies)Printed in the Newspaper (Separate fees apply- Staff will call with options)No 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.
Cancelof
My loved one wishes for:

Traditional Viewing with burial or entombment to followTraditional Viewing with cremation to followCremation with Memorial Service (Celebration of Life Service)Private family viewing with Cremation to followImmediate Cremation with no rites or ceremonies (Direct Disposal)Other
Does the decedent own Cemetery property?

YesNo
If yes, which Cemetery?
Example: Olive Cemetery, Fairview Cemetery, Etc.
Online Form Submission Disclaimer

Please be advised that the online submission of forms through this platform is a service provided for your convenience. Cruz Family Funeral Home, its affiliates, and representatives shall not be held responsible for any issues, errors, delays, or omissions that may occur during the online form submission process.

By choosing to submit forms online, you acknowledge and agree that:

Responsibility: Cruz Family Funeral Home is not responsible for any technical malfunctions, network issues, or other factors that may result in the non-receipt or delayed receipt of your submitted forms.
Accuracy of Information: You are responsible for ensuring the accuracy and completeness of the information provided in the online forms. Cruz Family Funeral Home is not liable for any inaccuracies, omissions, or errors in the submitted information.
Confirmation of Submission: Submission of forms online does not guarantee their immediate or successful receipt by Cruz Family Funeral Home. It is recommended to follow up with the funeral home directly to confirm the receipt of your submitted forms.
Security: While reasonable measures are taken to secure the online form submission process, Cruz Family Funeral Home cannot guarantee the absolute security of information transmitted over the internet. Submitting sensitive information is at your own risk.
Changes to the Disclaimer: Cruz Family Funeral Home reserves the right to modify or update this disclaimer at any time without prior notice. It is your responsibility to review the disclaimer periodically for any changes.
By signing below and proceeding with the online submission of forms, you acknowledge that you have read, understood, and agreed to the terms and conditions outlined in this disclaimer.

If you do not agree with any part of this disclaimer, please refrain from submitting forms online and contact Cruz Family Funeral Home directly for alternative submission methods.
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Vital Statistics

Surviving Relatives and Personal Information: