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Personal Information of Deceased

DECEDENT'S NAME (First, Middle, Last, Suffix)

SEX

APPROX WEIGHT

DATE OF BIRTH

AGE

UNDER 1 YEAR

UNDER 1 DAY

DATE OF DEATH

SOCIAL SECURITY NUMBER

BIRTHPLACE (City & State or Foreign Country)

COUNTY OF DEATH

PLACE OF DEATH

IF HOSPITAL

IF NON-HOSPITAL

IF OTHER SPECIFY

FACILITY NAME (If not institution, give street address)

CITY, TOWN, OR LOCATION OF DEATH

INSIDE CITY LIMITS?

YES

NO

MARITAL STATUS

SURVIVING SPOUSE (If wife, give maiden name)

RESIDENCE-STATE

COUNTY

CITY, TOWN, OR LOCATION

STREET ADDRESS

APARTMENT #

ZIP CODE

INSIDE CITY LIMITS?

YES

NO

DECEDENT'S USUAL OCCUPATION

KIND OF BUSINESS/1NDUSTRY

DECEDENT'S RACE (Specify race/races to indicate what the decedent considered himself/herself to be. More than one race may be specified)

Specify

DECEDENT OF HISPANIC OR HAITIAN ORIGIN?

YES (IF YES, SPECIFY)

NO

HISPANIC

OTHER HISPANIC (SPECIFY)

DECEDENT'S EDUCATION (Specify the decedent's highest degree or level of school completed at time of death.)

WAS THE DECEDENT EVER IN U.S. ARMED FORCES?

YES

NO

FATHER’S NAME (First, Middle, Last, Suffix)

MOTHER'S NAME (First, Middle, Maiden Surname)

INFORMANTS NAME

RELATIONSHIP TO DECEDENT

PHONE

STREET ADDRESS

CITY OR TOWN

STATE

ZIP CODE

BEST TIME TO REACH VIA PHONE*

DO YOU HAVE A PREARRANGEMENT ON FILE WITH US?

IF YES, UNDER WHAT NAME?

NUMBER OF CERTIFIED COPIES

EMAIL

Opt-In

TO A VOID A POSSIBLE AMENDMENT FEE OF $100.00, IT IS THE RESPONSIBILITY OF THE BUYER/CO-BUYER TO ENSURE THAT ALL THE INFORMATION PROVIDED ON THIS WORKSHEET IS ACCURATE. BY SIGNING YOU ARE AGREEING THAT THE INFORMATION ABOVE IS CORRECT AND THEREFORE WILL BE FILED WITH THE STATE AS SUCH.

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