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Deceased's Information
First Name of Deceased
Middle Name of Deceased
Last Name of Deceased
Also Known As (AKA)
Home Address*
City*
State
Zip Code*
Gender:
Male
Female
Social Security Number*
Will there be a funeral or memorial service?
Yes
No
Number of Certified Death Certificates*
Race (white, black, American Indian, etc.)
Of hispanic origin?
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, Other Spanish/Hispanic/Latino
Unknown
Not obtainable
Refuse to answer
Life
Date of Birth*
Place of birth
Date of Passing
Known
Unknown
Date of Passing
Time of Passing
Hours
:
Minutes
AM
PM
AM/PM
Date (from)
Time of Passing
Hours
:
Minutes
AM
PM
AM/PM
Date (to)
Time
Hours
:
Minutes
AM
PM
AM/PM
Date of Pronouncement
Time of Pronouncement
Hours
:
Minutes
AM
PM
AM/PM
Cause of Death
What was the place of death?
Selection
As an inpatient at a hospital
In the emergency room
On the way to the hospital
At a hospice facility
At a nursing home or long-term care facility
At a nursing home or long-term care facility
At home
At another location
Specific location of passing
Physician's Name
Physician's Phone Number
Physician's Fax Number
Resting Place
Resting Place
Burial
Cremation
Donation
Entombment
Other
Where will deceased be laid to rest?
When will deceased be laid to rest?
Marriage
Family Information
Never Married
Divorced
Married
Widowed
Domestic Partner
Spouse/Partner First Name
Spouse/Partner Middle Name
Spouse/Partner Last Name
Spouse/Partner Maiden Name (If Female)
Education
Select the highest level of education achieved*
8th grade or less
9th-12th grade; no diploma
High School graduate or GED completed
Some college credit, but no degree
Associate degree
Bachelor's degree
Master's degree
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
Degree not listed here
Unkown
Refuse to answer
Parents
Fathers Full Name*
In which city was deceased father born?
Living?
Living
Deceased
Mothers Full Name*
Mothers Maiden Name*
In which city was deceased mother born?
Living?
Living
Deceased
Military
Did deceased serve in the U.S. Military?
Yes
No
Unknown
Highest Military Rank
Number of Years Served
Military Service Number
Military Honors
Did a service-connected disability contribute to deceased death?
Yes
No
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Untitled
