Vital Statistics Form Please provide the following information. Step 1 of 7 14% Decedent's Legal First Name Middle Last Suffix Maiden Last Name Sex Male Female Social Security # Birth Date Month Day Year Date of Death Month Day Year Age Please enter a number from 0 to 110. If Under 1 Year Please enter a number from 0 to 11. Months Days Please enter a number from 0 to 30. If under 1 Day Please enter a number from 0 to 23. Hours Minutes Please enter a number from 1 to 59. Birth City Birth State Did Person Serve in the United States Armed Forces? Yes or No. Did Decedent serve in a combat zone? Yes No Location Of Combat Zone Honorable Discharge Yes No Military Branch Dates In Service Rank S# C# Current 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 County of Death Inside City Limits Yes No Marital Status at Time of Death MarriedWidowedNever MarriedLegally SeparatedDivorcedUnknown Spouse's Full Name w/ MAIDEN LAST NAME Spouse's Date Of Birth Month Day Year Spouse's SSN Father's First Name Middle Last Suffix Mother's First Name Middle Last (Maiden) 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 Email Address Telephone Number Type Of Arrangement Desired Burial Cremation If Cremation, what would you like done with the ashes? Name Of Cemetery (if any) Occupation for most of life Kind of Business/ Industry 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 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 Name This field is for validation purposes and should be left unchanged.