Vital Statistics Form

• Deceased Information

• Legal Name of Deceased*
  First Middle Last
• Sex
  MaleFemale
• Date of Death
  MM slash DD slash YYYY
• Birthdate
  MM slash DD slash YYYY
• Birthplace
  City and State or Foreign Country
• Social Security Number

• 
  

  Residence Information

• Decedent's Residence
  Street Address City State / Province / Region ZIP / Postal Code
• Tribal Reservation (If any)
• Years at Residence
• Is this address inside city limits?
  YesNoUnknown

• 
  

  Demographic Information

• Highest Level of Education
  8th grade or less9th - 12th grade; no diplomaHigh School Diploma or GEDSome college credit; no degreeAssociate's degree, AA, AS, etc.Bachelor's degree, BA, BS, etc.Master's degree, MA, MS, MEng, MEd, MSW, MBA, etc.Doctorate, PhD, EdD, etc.Professional degree, MD, DDS, DVM, LLB, JD, etc.OtherUnknown
• Other Education
• Hispanic Origin or Descent
  No, Not Spanish/Hispanic/LatinoYes, Mexican, Mexican-American, ChicanoYes, Puerto RicanYes, CubanYes, Other Spanish/Hispanic/LatinoUnknown
• Other Hispanic Origin or Descent
• Race
  White, CaucasianBlack, African AmericanAmerican Indian or Alaska NativeAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawaiianGuamanian or ChamorroSamoanOther Pacific IslanderOther, Please SpecifyUnknown
• Name of the enrolled or principal tribe
• Other Pacific Islander
• Other Asian
• Other Race
• Served in Armed Forces?
  NoYesUnknown
• Marital Status
  MarriedMarried, but separatedDivorcedNever MarriedWidowedDomestic PartnershipUnknown

• 
  

  Personal Details

• Surviving Partner
  First Maiden Name
• Usual Occupation
• Kind of Business / Industry
  Please Select IndustryAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherUnknown
• Other Industry
• Father's Name
  First Last
• Mother's Name before first marriage
  First Maiden Name
• Primary Care Physician
• Dr. Phone Number

• 
  

  Contact Details

• Your Name*
  First Last
• Your Phone Number*
• Your Email Address*

• 
  

  It's very important to double check this information for errors before clicking 'Submit' as it will be used to generate the death certificate. Mistakes can be costly and cause lengthy delays in the availability of certified copies. If you need more time to complete this form you can use the link below to save your progress and finish later.
• Name
  This field is for validation purposes and should be left unchanged.

Save and Continue Later