Decedent Initial Information

Please accept our sincere sympathies on losing your loved one. At this challenging time, we do our best to have the arrangement process flow smoothly for the family. With this in mind, you may complete the following form to supply us with the information we will require for the death certificate. If you desire, we can also fax or email the required documents to you for your signature.

If you have any questions, please do not hesitate to contact us.

Decedent Personal Information

First Name

Middle Name

Last Name

AKA. Also Known as

Date of Birth

Age (years)

Sex

Birth State/Foreign Country

Social Security Number

Date of Death

Hour of Death (24 hours)

Education (highest level)

Usual Occupation

Kind of Business or Industry

Years in Occupation

Decedant's Race

Decedent Usual Residence

Decedent's Residence

Street Address Address Line 2 City State ZIP Code

Years in County

If in county for less than 1 year - specify 0

Was there military service?

Military Service Information

Branch of Service

Have discharge papers (DD214)?

Marital Status?

Marriage Information

Spouse Name

Spouse Maiden Name

Informant - Person Completing this Form

First Name

Last Name

Relationship

Informant Address

Street Address Address Line 2 City State ZIP Code

Phone

Parents

Name of Father - first

Middle

Last

Birth State of Father

Name of Mother - first

Middle

Last (maiden)

Birth State of Mother

Any additional Information

Please specify any addition information that your wish regarding funeral services or your wishes.

Disposition Choice

Number of death Certificates Neeeded ($24 each)

Please enter a number from 0 to 20.

Type of Services Interested in

(ctrl+) for multiple selections