EmailMe Form - Vital Statistics

Name *
First Middle Last Suffix
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please enter the mailing address of the Legal Next of Kin
Email *
Please enter your Email address
Phone *
### - ### - ####
Please enter your phone number so that one of our Funeral Director's can get in touch with you if needed.
Relationship *
What is the Legal Next of Kin's relationship to the decedent
Decedent's Information
This information will be used to generate the Death Certificate for the Doctor's signature
Decedent Name *
Prefix First Middle Last Suffix
Please enter the complete name for the Deceased
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Please enter the last residential address of the deceased.
Date of Birth *
MM / DD / YYYY
Please enter the date of BIRTH for the decedent
Place of Birth *
City, State - Decedent's Place of Birth
Date of Death *
MM / DD / YYYY
Please enter the date of DEATH for the decedent
Social Security Number *
Please enter the Social Security Number for the decedent
Sex *
Male
Female
Please enter the gender of the decedent
Race *
White
Black or Africian American
American Indian
Asian Indian
Chinese
Flipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Samoan
Other Pacific Islander
Unknown
Not Obtainable
Refused
Other
Please select the Race of the Decedent
Martial Status *
Please list decedent's martial status at the time of their death.
Spouse Name
First Middle Last
If Married, Please enter the name of the Spouse
Maiden Name
If Married, Please enter the maiden name for the wife
Father's Name *
Prefix First Middle Last Suffix
Please enter the decedent's fathers name.
Unknown is a valid choice if name is not known
Mother's Name *
Prefix First Middle Last Suffix
Please enter the decedent's mothers name
Unknown is a valid choice if name is not known
Mother's Maiden Name *
Please enter mother's maiden name
Unknown is a valid choice if name is not known
Education *
Unknown
8th Grade or Less
9-12, No diploma
H.S. Diploma or G.E.D.
Some College, No Degree
Associates Degree
Bachlor's Degree
Master's Degree
P.H.D., Professional Degree
Enter the decedent's highest level of education attained
Usual Occupation *
Please describe the type of work decedent performed the majority of their working years
Unknown is a valid option if Occupation is not known.
Industry *
Please describe the Industry of occupation
Unknown is a valid option if not known.
Veteran *
Yes, Honorable Discharge
Yes, Other type of discharge
No
Was the decedent ever in the U.S. Military?
DD214 Available
Yes
No
Do you have a legible copy of the Military Discharge document (Routinely called a DD214)
DD214 Upload
Please upload a copy of the DD214 Discharge if available
Branch of Service
Date of Entry
MM / DD / YYYY
Date of entry into the Military
Date of Discharge
MM / DD / YYYY
Date of discharge from active duty military

Decedent's Information