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 /
Bachelor’s / Master’s / 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 _________________________
Deceased’s Parents
Father’s First Name_______________________Middle_____________Last_______________________
Mother’s 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_________________________________