Vital Statistics Form

Deceased Full Legal Name

Most Recent Address of Deceased


Marital Status

Highest Level of Education

Date of Birth

City & State of Birth

Father's Name

Mother's Name

Usual Occupation (before retirement)

Military Branch (if veteran)

Surviving Spouse Name

Informant or Next of Kin

This is the name and address that will appear on the death certificate of the person responsible for arrangements.

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