Funeral Home Vital Information

These are the questions that the funeral director will need to accurately complete the death certificate and cremation permit.

These are legal documents and require accuracy. There are a few questions at the conclusion of the form concerning obituaries and notices that you may opt out of.

If you do not know the answer to a question you may skip it for now but the information will likely be required to file the death certificate.

The state typically will not issue death certificates will fields marked "unknown".

Name of Decedent

PrefixFirst NameMiddle NameLast NameSuffix

MaleFemaleother

Decedent's Social Security Number

Did the decedent serve in the US Armed Forces?

Age of deceased

Date of birth

Date

Place of birth

Date of death

Date

Place of death

Decedent’s physical address (No P.O. Boxes)

Street Address

Street Address Line 2

City, CountyState

Zip Code

Name of attending physician, or primary care doctor

First NameLast Name

Fathers full name

PrefixFirst NameMiddle NameLast NameSuffix

Mothers full name (including maiden)

First NameLast NameSuffix

Decedent's highest level of education

Usual occupation during most of working life.

Kind of business / industry

Marital Status

Last name of decedent at birth (Maiden name)

Decedent’s Spouse's Maiden name

PrefixFirst NameMiddle NameLast NameSuffix

Spouse's address if different than decedent's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Name (Next of Kin, Informant to State)

First NameLast Name

What is the informant's relationship to the decedent?

Informant's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Informant's mobile phone number

Area CodePhone Number

Email address of informant

example@example.com

Final Disposition of decedent

Name of cemetery

Are there any individuals having greater or equal authority to the right of disposition than the informant? If so please list them below.

We offer a free obituary listing on our website, xxxxxxxxxxxxxxxxxxxx.com to every family that we serve.

Its a place for:

photo or photos
an obituary, or life story
events (memorial or funeral services)
messages from family and friends

The next three sections will allow you to upload an obituary and photo, or you can email that to us later at

xxxx@xxxx.com

Please upload a photo of decedent

You may use this section to type a short obituary if you would like. More templates and help can be found at https://www.obituaryhelp.net

Document Upload

Browse Files

Thank you for taking the type to fill out this questionaire

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If you have any questions please reach out at ______________

xxxx@xxxxx.com