Vital Statistics Form
Provide the decedent’s personal, race, education, and informant details, then sign and date the approval section.
Decedent’s Personal Data
Decedent’s Name (First, Middle Initial, Last)
*
First Name
Middle Name
Last Name
AKA / Also Known As
First Name
Middle Name
Last Name
Date of Birth (MM-DD-YYYY)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age in Years
Sex
Female
Male
Unknown
Age at Death: Days (if under one year)
Age at Death: Months (if under one year)
Age at Death: Hours (if under 24 hours)
Age at Death: Minutes (if under 24 hours)
Date of Death (MM-DD-YYYY)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour of Death (24-hour format)
Hour Minutes
AM
PM
AM/PM Option
Birth State or Foreign Country
*
Ever Served in the U.S. Armed Forces?
*
Yes
No
Unknown
Marital Status at Time of Death
*
Please Select
Never married
Married
Widowed
Divorced
Separated
Unknown
Highest Education Level or Degree
*
Please Select
No formal education
Elementary or middle school
Some high school
High school graduate or equivalent
Some college credit, no degree
Associate degree
Bachelor’s degree
Master’s degree
Doctoral or professional degree
Unknown
Spanish, Hispanic, or Latino?
*
Yes
No
Unknown
Race (select up to 3)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Unknown
Other
Usual Occupation (Type of Work for Most of Life; Do Not Enter “Retired”)
Kind of Business or Industry (e.g., Grocery Store, Road Construction, Employment Agency)
*
Years in Occupation
*
Usual Residence Information
Residence Street and Number or Location
*
Residence City or Town
Residence State
Residence ZIP Code
State or Foreign Country of Residence
Years in Country
*
Informant Name
*
First Name
Last Name
Informant Relationship and Mailing Address (Street and Number or Rural Route, City or Town, State, ZIP)
*
Decedent Spouse Information
Surviving Spouse Name
First Name
Middle Name
Last Name
Decedent Parent Information
Father’s First Name
*
Father’s Middle Initial
*
Father’s Last Name
*
Father’s Birth State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Other
Mother’s First Name
*
Mother’s Middle Initial
*
Mother’s Last Name
*
Mother’s Birth State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Other
Customer Approval
Customer Signature
*
Date (MM-DD-YYYY)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: