Vital Statistics Information Form

Please Note: All information on this form must be completed accurately and in full, as required for the Michigan Certificate of Death. If any information is unknown, please indicate “unknown.” The funeral home records the information exactly as provided by the informant and is not responsible for errors or omissions in the information supplied.

1.) Decedent's Name

First NameMiddle NameLast Name

2.) Date of Birth

Month, Day, Year

3.) Sex

4.) Date of Death

Month, Day, Year

5.) Name at birth or other name used for personal business (include AKA's if any)

First NameMiddle NameLast Name

6.a) Age (Last Birthday)

Years

7.a) Location of Death - Hospital or Other Institution

Enter place officially pronounced dead in 7a, 7b or 7c) - If not either, give street and number and zip code.

7.b) City, Village or Township of Death

Ex. Mt. Pleasant or Union Township

7.c) County of Death

Ex. Isabella County

8.a) Current Residence - State

Ex. Michigan

8.b) Current Residence - County

Ex. Isabella County

8.c) Current Locality (check the box that describes the location)

8.d Street and Number

Include apartment no. if applicable.

8.e) Zip Code

Ex. 48858

9.) Birthplace (City and State or Country)

Ex. Mt. Pleasant, Michigan or United States

10.) Social Security Number

11.) Decedent's Education

(What is the highest degree or level of school completed at the time of death?) Ex. High school, bachelors degree,

12.) Race/Heritage (Enter all that apply)

Ex. White, American Indian, Black, Chinese - If Asian, list nationality ie. Chinese, Filipino, Asian Indian, etc.

13.a) Ancestry (Enter all that apply)

Ex. English, German, Saginaw Chippewa Indian Tribe, etc. If American Indian race, please provide principal tribe.

13.b) Hispanic Origin? (Yes or No)

14.) Was Decedent ever in the U.S. Armed Forces? (Yes or No)

15. Usual Occupation

Give kind of work done during most of working life. Do not use retired.

16.) Kind of Business or Industry

Ex. Construction, Real Estate.

17.) Martial Status (Specify)

18.) Name of Surviving Spouse (If applicable)

If wife, give maiden name before first married.

19.) Father's Name

First NameMiddle NameLast Name

20.) Mother's Name (Maiden Name)

First NameMiddle NameLast Name

21.a Informant's Name

First NameLast Name

21.b) Relationship to Deceased

Ex. son, daughter, spouse

21c.) Informant's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reminder: All information on this form must be completed accurately and in full, as required for the Michigan Certificate of Death. If any information is unknown, please indicate “unknown.” The funeral home records the information exactly as provided by the informant and is not responsible for errors or omissions in the information supplied.

Vital Statistics For Certificate of Death