Page 54 - 2024-04 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.

Name: first: ___________________________________ middle: __________________________ last: _________________________________

SSN: __________________________________________ DOB: _______________________________________ male female

AGE: ____________________________ Birthplace: ___________________________________________________________________________

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

City: __________________________________________________________ State: ___________________ Zip Code: _____________________

Inside City Limits? yes no

Marital Status: Widow Divorced Married Never Married

Surviving Spouse’s Full Name: first: ________________________middle: _______________________ last: ______________________________
(if wife, give maiden name)
Father’s Full Name: first: __________________________ middle: ________________________ last: ______________________________

Father’s Birth Place: City: ________________________________________ State: ___________________ country: _____________________

Mother’s Full Maiden Name: first: _____________________ middle: _________________________ maiden: ___________________________

Mother’s Birth Place: City: _______________________________________ State: ___________________ country: _____________________

Informant’s Name: first: ____________________________ middle: ________________________ last: ________________________________
(individual providing this information)
Relationship: __________________________________________________ Phone: _________________________________________________

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: ___________________________________________ Race: ____________________________________________

Veteran: YES NO Branch: ________________________________________________________________________________

Attending Physician: ____________________________________________ How Many Certified Copies: _______________________________

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