Vital Information Form DESKTOP and MOBILE

Let's get started.

We want to get to know who your loved one was...
What was your loved one's favorite thing to do?
What was your loved one best known for?
What's your loved one's happy place?
Would you like a free online obituary for your loved one on our site?*

YesNo

Thank you for sharing.

The rest of the information in this form is used to accurately complete the death certificate and cremation permit. These are legal documents that require accuracy. All information is secured & used for these purposes only.
Name of Decedent *

First NameLast Name
Middle Name
Middle Name
Decedent's Sex*

MaleFemale
Decedent's Social Security Number*
Did the decedent serve in the US Armed Forces?*
Age of Deceased*
Decedent's Date of Birth*

MonthDayYear
Date
Decedent's Place of Birth*

Date of Death*

MonthDayYear
Place of Death*
What County Did The Death Take Place In?*
Decedent's Address/Place of Residence*

Street Address

County

CityState

Zip Code
Decedent's Residence:*

CityVillageTownshipUnincorporatedUnknown
Name of Attending Physician or Primary Care Doctor

First NameLast Name

Decedent's Highest Level of Education*
Decedent's Occupation Most of Life. *
Occupation's Business/Industry*

Decedent's Marital Status*
Decedent's Maiden Name (If Applicable)
Decedent’s Spouse's Name

First NameLast Name
Decedent's Spouse's Maiden Name (If Applicable)
Decedent's Spouses Address (If different than decedent's)

Street Address

Street Address Line 2

CityState

Zip Code

Your Name (Informant to State/Next of Kin)*

First NameLast Name
What is the Your Relationship to the Decedent?*
Your Address*

Street Address

CityState

Zip Code
Your Phone Number*
Your Email Address*

How did you hear about us?*
State*
By signing this document, you acknowledge and approve that you are the legal entity permitted to carry out the cremation of this individual and that you have filled out the documentation with full accuracy.*

Clear
Should be Empty: