Vital Statistics Form | Greener Pastures Funeral Home

If A Death Has Just Occurred

Vital Statistics Information Form

Prefix

First Name

Middle Name or Middle Initial ( Type NA for None)

Last Name: If Female indicate Maiden Name

Date of Birth*

Social Security Number*

Sex

Social Security Number ###-##-####

Date Of Birth

Age

State of Birth

City of Birth

Free Text

Decedent's Address

Street

City

State

ZIP/Postcode

County

Inside City Limits

Was Decedent in Military of Armed Forces ?

Decedent's Last Occupation

Kind of Business or Industry

Last Employer

Marital Status

Spouse Name (Maiden name if Female)

Decedent's Fathers Name

Decedent's Mothers Name (Maiden Name)

Decedent's Highest Level of Education

Informant's Name ( First, Middle Name of Initial, Last Name)

Informant's Address

City

State

ZIP/Postcode

Hispanic Origin

Yes, Other Spanish/Hispanic/Latino(Specify Below)

Decedent's Race

Specify Race from above if needed

Method of Disposition

Please indicate name of out-of-state funeral home

Address of out-of-state funeral home

City

State

ZIP/Postcode

Date of Burial or Entombment

Free Text

Contact information for person completing this form

Full Name

Address

City

State

ZIP/Postcode

Phone

Email

Vital Statistics Information Form

If A Death Has Just Occurred

Vital Statistics Information Form

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