Page 37 - McCriskin-Gustafson Funeral Homes

Name: (First, Middle, Last) Common Name/Nick Name:
Legal Address Street/Number:
Date Of Birth:
Social Security Number:
Marital Status: Single
Domestic Partnership:
Married No
City:
Divorced
State:
Widowed
Unknown
Information needed for the Death Certificate:
Spouse/Partner’s Full Legal Name:
Highest Education Level:
Parents Name
Mother’s Maiden Name:
Place Of Birth
City: State:
Fathers Name:
Yes
Foreign Country: Veteran Status: (Copies of discharge are usually needed)
Yes No Branch: Disposition: Burial Cremation
Provide Information of Cemetery Name: City/Town:
Last Occupation:
War: Rank: Entombment
Mausoleum:
(Copies of Deed/Papers)
Name, Address, Relationship and Phone Number of Person in Charge of Funeral Arrangements:
McCriskin-Gustafson Funeral Homes - Page 37