Has The Death Occurred
NO
Yes
Name of the Decedent
First
Middle
Last
Sex
Select Sex
Male
Female
Other
Aka
Date of Death
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Select Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Date of Birth
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Select Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Country or State of Birth
Social Security Number
ID Verification
Approximate Height
Approximate Weight
Marital Status
Married
Divorced
Widower
Never Married
Ever in the US Armed Forces?
No
Yes
Highest Education Level
Was Decedent Hispanic/Latino/Spanish ?
No
Yes
Decedent Race (May use up to 3 choices)
Occupation
(Do not write Retired, If retired, write the last work done)
Kind of Industry
(Transport, Medical, Government, Education etc.)
Years in Occupation
Decedent’s Street Address
City
Zip Code
County
Years lived in that County
Surviving Spouse’s Name
First
Middle
Last
Maiden
(Name before Marriage)
Decedent’s Father’s Name
First
Middle
Last
Decedent’s Father Birth Country or State:
Decedent’s Mother
First
Middle
Last
Maiden
(Name before Marriage)
Decedent’s Mother Birth Country or State:
Name & City of the Cemetery for Burial
Primary Care Physician
Physician Name
Hospital / Hospice
City
Physician's Phone
Last time seen by the Physician
(Approximate Date)
Informant’s Information:
Informant’s Name
Relationship to the Decedent
Informant’s Address
City
Zip
Informant’s Phone
Informant’s E-mail
Where would you like the Death Certificate to be mailed at
Select
Decedent’s Address
Informant’s Address
Decedent’s Location
Location
Select Decedent’s Location
Hospital
Assisted Living
Senior Housing
County Coroner
Private Residence
Other Funeral Home
Out of State
Prison
Address of The Facility
City
County
Would you like to order a Funeral Coach (Hearse) for transportation to the Cemetery for
$300
?
Yes
No