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Vital Statistics
In this section
Vital Statistics
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Cremation Authorization Form
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Caskets
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Urns
Vital Statistics Form
A. Information about the deceased
Last Name
Middle Name
Sex
Female
Male
First Name
Maiden Name
Father's First and Last Name
Mother's Maiden Name
Mother's First and Last Name
Decedent of Hispanic Origin?
Select below
Not SpanishHispanicChicano
MexicanMexican AmericanChicano
Puerto Rican
Cuban
Other specify in Comments section below
Comments
Decedent Race
Select below
White
Black or African American
Asian Indian
Chinese
Filipino
Japanese
Korean
Native Hawaiian
Vietnamese
Guamanian
Chamorro
Other Asian specify in Comments section below
Pacific Islander specify in Comments section below
Other specify in Comments section below
American Indian or Alaska Native specify in Comments section below
Comments
Date of Birth
City of birth
OR Country if not USA
State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Date of death
City of death
State of Death
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
County of death
Location of death
Name of the place of death ( or street address if residence)
Location (if other)
Social Security Number
Choose highest level of education completed.
Select below
8th or less
9-12 no diploma
High School Graduate or GED completed
Some college no degree
Associate Degree
Bachelor Degree
Masters Degree
Doctorate
Unknown
Veteran information
Was the decedent ever in the US Armed Forces?
Yes
No
If Yes, Branch of service
Employment History
Usual occupation (most of life)
Type of business/industry
Marital Status at time of death
Select below
Married
Never Married
Divorced
Widowed
Surviving Spouse Name including last name prior to first marriage, if applicable.
Surviving spouse address
Street
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
ZIP/Postcode
Informant information
Name of person in charge
Street
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
ZIP/Postcode
Home Telephone
Cell phone
Email Address
B. Type of disposition
Disposition will be: Cremation, Burial or Removal from State
Cemetery or other
Anticipated Ceremonies
C. Preparation and viewing
Viewing/Embalming Preference
Open Casket Visitation embalming required
No Viewing embalming not required
Transportation via common carrier ie air cargo embalming required
Use option required by disposition Unless embalming is required by the type of service chosen remains will be sheltered in a cooler as required by Florida law
Relationship to deceased
D. Funeral/memorial service information
Preferred place of service
Religious denomination
Are there pre-need funeral arrangements on decedent?
Yes
No
I don't know
If yes, specify type if known
Anti-Spam Security Question
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