Basic Vital Statistic Information


First Name________________________Middle______________________Last________________Suffix____

Doctor__________________Phone____________Social Security Number______-________-_________

Date of Birth______/______/______ (DOD___/_____/_____ TOD_________POD_________________)

Place of Birth (City and State or Foreign Country)_____________________________________________

United States Veteran YES / NO (Circle one) Branch__________ Rank_____________War________

Service Number________________Date Entered_____________Date Separated__________

Marital Status (Never Married, Married, Widowed, Divorced) Circle one / Are they living YES / NO

Most Recent Spouse (If wife, give maiden name)______________________________________________

Education (Circle one) 8th grade or less / 9-11 no diploma / High School or GED /Some college no degree / Associate /

Bachelorís / Masterís / Doctor or Professional

Ancestry:________________ If Hispanic;(Mexican, Cuban, Puerto Rican, etc)_______ Race:__________

What is your usual occupation? (Do not use retired )__________________Employer______________

Resident Address: State______________County__________________City or Town_______________

Street and Number______________________________________________________

Zip Code_____________________Telephone Number_________________________

Cell _________________________

Deceasedís Parents

Fatherís First Name_______________________Middle_____________Last_______________________

Motherís First Name____________________Middle_____________Last (Maiden)_________________

Contact Person

Name______________________________________Relationship________________________________

State________________County____________________City or Town____________________________

Street and Number__________________________Zip_______________Telephone_________________

Email/Fax______________________

Funeral Home Used? Yes / No

Funeral Home

Name______________________________________Relationship________________________________

State________________County____________________City or Town____________________________

Street and Number__________________________Zip_______________Telephone_________________

Email/Fax______________________

Method of Disposition________________Place of Final Disposition______________________________

Number of Certified Copies of the Death Certificate___________________________________________

Obituary requested_______Which papers___________________________ Already Paid For? __________


Signed_________________________________________ Date_________________________________