Vital Statistics Form Vital Statistics Name: * First Last: * Last Address: * City: * State: * Zip Code: * Spouse's Name (if wife, Maiden Name): * Sex: * Male Female Marital Status: * Never Married Married Widowed Divorced Race: Address of Death: * State * Zip Code * Date of Death: * Time of Death: * Date of Birth * Address of Birth: * City: * State: * Age: * Social Security Number: * Occupation: * Kind of Industry: * Doctor's Name: * Informant Name: Informant's Relationship to the Deceased: Informant's Address: City: State: Zip Code: Informant's Phone: Father's Name * Father's Birthplace: * Mother's Maiden Name * Mother's Birthplace: * Disposition Request: I Prefer * Earth Burial Mausoleum Cremation Other If Other: Address of Disposition: * City: * State: * Date of Disposition: * Place of Funeral: * Date of Funeral: * Time of Funeral: * Visiting Hours: * In Lieu of Flowers: Clergy Name: * Clergy Phone: Veteran? * Yes No Service Number: Enlistment Date: Enlistment Place: Date Discharged: Place of Discharge: Branch of Service Wars Fought In: Rank at Discharge Lot Information: Lot # (if applicable) Hair Dressing Instructions: Obituary Information Father: * Mother's Maiden Name: * Spouses Name: Son & Spouse: Address: Son & Spouse: Address: Son & Spouse: Address: Son & Spouse: Address: Daughter & Spouse: Address: Daughter & Spouse: Address: Daughter & Spouse: Address: Daughter & Spouse: Address: Brother & Spouse: Address: Brother & Spouse: Address: Brother & Spouse: Address: Brother & Spouse: Address: Sister & Spouse: Address: Sister & Spouse: Address: Sister & Spouse: Address: Sister & Spouse: Address: Grandchildren: Great Grandchildren: Newspaper Notices: Highest Grade Completed: * High School Vocational/Technical School Master's Doctorate More about Education: Employment: * Organizations: Submit If you are human, leave this field blank.
