Vital Information Form "*" indicates required fields Your Name:* Date: MM slash DD slash YYYY Email:* Phone:*Deceased Name:* First Middle Last Gender:* Male Female Date of Death:* MM slash DD slash YYYY Social Security Number:Age:*Date of Birth:* MM slash DD slash YYYY State or Country of Birth:* U.S. Military:* None Army Navy Marines Air Force Coast Guard Place of Death:* Hospital Hospice Residence Assisted Living/Nursing Home Other Name of Hospital, Hospice or Assisted Living/Nursing Home: City / County:* Deceased Occupation:* Marital Status:* Married Widowed Never Married Divorced Unknown Other Spouse (Provide Maiden Name): Deceased Resident State or Country:* Deceased Resident City:* Deceased Resident County:* Street Name:* Street Number:*Inside the City Limits?* Yes No Unknown Education:* Degree Type:* Is the Deceased of Hispanic Origin?* Yes No If Yes, Where: Race:* American Indian White Black Asian Hispanic Arab East Indian Other Deceased Mother's Name (Maiden Name):* Deceased Father's Name:* Informant's Name (Your Name):* Informant's Relationship to Deceased:* Disposition Requested: Burial/Intombment Cremation Removal from State Donation Other If Burial, what Cemetery:* City/State:* Initial:* Date MM slash DD slash YYYY CAPTCHA Δ
