Death Certificate Information
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Deceased Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
SSN
*
Place of Birth (City & State)
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation (Cannot use Retired)
*
Type of Industry/Business
*
Marital Status
*
Married
Never Married
Divorced
Widowed
Education
*
Surviving Spouse (Maiden Name)
Prefix
First Name
Middle Name
Last Name
Suffix
Race
*
Ancestory (Dutch, German, English, American....)
*
Hispanic Origin
*
Yes
No
U.S. Armed Forces Member
*
Yes
No
Father's Name
*
Prefix
First Name
Last Name
Suffix
Mother's Name (Maiden Name)
*
Prefix
First Name
Last Name
Suffix
Back
Next
Informant's Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Relationship to Deceased
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
-
Area Code
Phone Number
E-mail
*
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