Page 54 - 2022_03 Resource Guide

Vitals For Death Certificate

This is the information necessary for the filing and obtaining certified copies of the death certificate.
In most cases, once we have this information it is just a matter of days
before we have the death certificate ready for you.

Full Name: _____________________________________________________________________________________________________________

SSN: ____________________________________________________ DOB: _________________________________________________________

AGE: ____________________________ Birthplace: ___________________________________________________________________________

Residence (at time of death) Street & Number: __________________________________________________________________________________

City: __________________________________________________________ State: ___________________ Zip Code: _____________________

Marital Status: Widow Divorced Married Never Married

Surviving Spouse’s Full Name (if wife, give maiden name): _________________________________________________________________________

Spouse’s DOB: ____________________________

Father’s Full Name: __________________________________________________ Father’s Birthplace: _________________________________

Mother’s Full Maiden Name: __________________________________________ Mother’s Birthplace: ________________________________

Informant’s Name (individual providing this information): ___________________________________________________________________________

Relationship: ___________________________________________________________________________________________________________

Informant’s Mailing Address Street & Number: ______________________________________________________________________________

City: __________________________________________________________ State: ___________________ Zip Code: _____________________

Decedent’s Usual Occupation (indicate type of work during the majority of working life): ______________________________________________

Position: _____________________________________________________ Industry: _______________________________________________

Level of Education Obtained: ______________________________________________________________________________________________

Veteran: YES NO Race: __________________________________________ How Many Certified Copies: ____________

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