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Name
Sex
Age
Social Security Number
Email
Date of Birth
Date of Death
Street
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Maine
Manitoba
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Massachusetts
Michigan
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Mississippi
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North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
ZIP/Postcode
Country
Marital Status
Inside City Limits?
Yes
No
Unknown
Armed Forces
Yes
No
Unknown
Occupation
Nature of Business
Employer
Spouse's Name
Father's Full Name
Mother's Full Name
Decedent's Education
8th grade or less
9~12th, grade, no diploma
High school diploma, GED
Some college
Associate degree
Bachelor's degree
Master's degree
Doctorate
Unknown
Informants Name
Relationship to the Decedent
Mailing Address
Street
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
ZIP/Postcode
Hispanic Origin
No, not Spanish/Hispanic/Latino
Yes, Pueto Ricain
Yes, Mexican, Mexican American, Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino(specify)
Unknown
Other/Specify
Decedents Race
White
Japanese
Asian Indian
Chinese
Filipino
Black/African American
Korean
Vietnamese
Native Hawaiian
Guamanian/Chamorro
Samoan
American Indian/Alaska Native
Other Asian
Other Pacific Islander
Other
Unknown
If death occurred in hospital
Inpatient
Emergency Room/Outpatient
Dead on Arrival
If death occurred other than hospital
Hospice Facility
Nursing Home/Long Term Care Facility
Decedent's Home
Other
Unknown
Facility Name
Facility Address
Country of Death
Method of Disposition
Burial
Donation
Removal from State
Cremation
Emtombment
Other
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