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: Place 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 # 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 Associates Bachelors Masters Doctorate More about Education: Employment: Organizations: Submit If you are human, leave this field blank.
