Vital Statistics
This information is required for the completion of the death certificate and other legal forms.
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for Spouse/Domestic Partner
Legal Information
First Name __________________________ Middle ________________________ Last ___________________________________
Address ________________________________________________________________________________________________
City/County/State/ZIP _______________________________________________________________________________________
Email address _____________________________________________________________________________________________
Home phone _________________________________________ Cell phone ___________________________________________
Gender Male Female
Date of birth ________________________ Place of birth __________________________________________________________
Social Security Number _____________________________________________________________________________________
Marital Status
Never married Married Widowed Divorced
Name of surviving spouse (including maiden name) ______________________________
Occupation
Most recent occupation _____________________________________________________________________________________
Place of employment (last or longest)____________________________________________________________________________
Type of business or industry __________________________________________________________________________________
Race (check the box that best describes your race)
White/Caucasian Asian Black or African American Other (specify) _____________________
Education (check the box that best describes the highest degree or level of school completed)
8th grade Associate’s degree
9th-12th grade, no diploma Bachelor’s degree
High school graduate or GED Master’s degree
Some college credit, but no degree Doctorate or professional degree
Veteran Information
Have you ever been a member of the armed forces? Yes No
What branch of service?
Army Navy Air Force Marine Corps Coast Guard Other (specify) ______________________
Parents
Name of father ____________________________________ Maiden name of mother ____________________________________
Place of birth ______________________________________ Place of birth ____________________________________________
Informant or Next of Kin (include relationship)
Name ______________________________________________ Relationship __________________________________________
Address ________________________________________________________________________________________________
City/State/ZIP ____________________________________________________________________________________________
Home phone _____________________________________________________________________________________________
Cell phone _______________________________________________________________________________________________
E-mail address ____________________________________________________________________________________________