Vital information - fill out Email Address * Phone (###) ### #### First Name of Decedent Middle Name of Decedent (if applicable) Last Name of Decedent Sex Male Female Not Determined Date of Death MM DD YYYY Date of Death Actual Approximate Presumed Found On Date of Birth MM DD YYYY Age Age (if under 1 year) Please enter the months and days Age (if under 1 day) Please enter the hours and minutes Was Decedent Ever in Armed Forces? Yes No Unknown Birthplace (U.S. State or Foreign Country) Social Security Number If NO SSN, check appropriate box None Not Obtainable Unknown Street Address of Decedent (Include House AND/OR Apt. # or Route N0.) City or Town of Residence Inside City or Town Limits? YES NO County of Decedent's Residence (if independent city, leave blank) U.S. State (Or Foreign Country) of Decedent's Residence Zip Code Race of Decedent (Check one or more) White Asian Indian Native Hawaiian Black or African American Chinese Guamanian or Chamorro Filipino Samoan Japanese Korean Vietnamese Unknown American Indian or Alaskan Native Other Pacific Islander Other Asian Other Specify if American Indian or Alaskan Native is checked Specify if Other Pacific Islander is checked Specify if Other Asian is checked Specify if Other is checked Decedent of Hispanic Origin? Non-Hispanic Central or South American Cuban Mexican Puerto Rican Unknown Other Specify if Other of Hispanic Origin is checked Education (Highest Grade Completed) Elementary/Secondary (0-12) High School Diploma GED Few years of college Associate Degree Bachelor's Degree Master's Degree Doctorate/Professional Degree Unknown Specify year of education if Elementary/Secondary (0-12) checked Specify how many years of college if Few years of college checked Citizen of what Country Usual or Last Occupation Kind of Business or Industry Marital Status Never Married Married Widowed Divorced Separated Unknown If Married, Separated or Widowed, Name of Spouse (if divorced, leave blank) Father's Name or Parent II (first, middle, last, suffix) (maiden name, if any) Father's or Parent II's Gender Mother's Maiden Name or Parent I (first, middle, last, suffix) (maiden name, if any) Mother's or Parent I's Gender Informant's Relationship or Source of Information Full Name of Informant or Name of Source Name of Hospital or Institution of Death (if none, so state) Select one if Death Occurred in Hospital DOA Out. Pat. Emer. RM Inpatient Specify if Death Occurred Somewhere other than a Hospital Hospice Facility Nursing Home Long Term Care Facility Decedent's Home Correctional Facility Other Specify if Other City or Town of Death Street Address or Rt. N0 of Place of Death Zip Code County of Death (if independent city, leave blank) Cemetery Name Cemetery Address Thank you!
