Vital Information Form

If you have not yet contacted the funeral home to notify them of a passing, please do so prior to filling out this information.

Decedent's Name:

Gender:

Date of Birth:

Date of Death:

Age:

Social Security Number:

Place of Death:

Place of Death Facility Name:

City or Location of Death:

County of Death:

Birthplace (City and State or Foreign Country):

Marital Status:

Surviving Spouse (Maiden Name):

Residence Address:

City:

State:

County:

Zip Code:

City Limits:

Occupation Prior to Retirement

Type of Business/Industry:

Race:

Hispanic/Haitian Origin:

Education:

Decedent in Armed Forces:

Father's Name (First, Middle, Last)

Mother's Name (First, Middle, Maiden)

Informant's Name:

Relationship:

Informant Address:

City:

State:

ZipCode:

Home Phone#

Cell Phone#

Family Remarks

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