Vital Statistics Form Please provide the following information. Step 1 of 4 25% Decedent's Legal First Name Middle Last Suffix Date of Death MM DD YYYY Birth Date MM DD YYYY Age Please enter a value between 0 and 110. If Under 1 Year Please enter a value between 0 and 11. Months Days Please enter a value between 0 and 30. If under 1 Day Please enter a value between 0 and 23. Hours Minutes Please enter a value between 1 and 59. Social Security # Sex Male Female Birth City Birth State Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Inside City Limits Yes No County of Death Decedent Education 8th grade or less9th – 12th grade, No DiplomaHigh school graduate or GED completedSome college credit, but no degreeAssociates degreeBachelors degreeMasters degreeDoctorate degreeRefusedNot obtainableUnknownNot classifiable Was Decedent Hispanic in Origin? No, Not Hispanic Yes, Check all of the following that apply Mexican, Mexican-American, Chicano Puerto Rican Cuban Other Spanish/Hispanic/Latino Specify Decedent Race White or Caucasian Black or African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other Specify Occupation for most of life Kind of Business/ Industry Marital Status at Time of Death MarriedWidowedNever MarriedLegally SeparatedDivorcedUnknown Spouse's Date Of Birth MM DD YYYY Spouse's Name (Maiden) Spouse's SSN Military Branch Rank S# C# Dates In Service Honorable Discharge Yes No Did Decedent serve in a combat zone? Yes No Location Of Combat Zone Father's First Name Middle Last Suffix Mother's First Name Middle Last (Prior to first marriage) Informant's Name Relationship to Decedent WifeHusbandMotherFatherSisterBrotherDaughterSonOther If other please specify relationship Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number Place of Death Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type Of Arrangement Desired Burial Cremation Name Of Cemetery (if any) If Cremation, what would you like done with the ashes?