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Online Planning – Step 4
Vital Stats
Deceased Vital Statistics for Death Certificate
First Name:
Last Name:
Middle Name:
Sex:
Race:
Date of Birth:
Place of Birth:
City:
State:
Country:
Date of Death:
City of Death:
State of Death:
County of Death:
Location of Death:
If other, please indicate address:
Name of the Place of Death:
Education:
Usual Occupation (most of life):
Kind of Business:
Company:
Marital Status:
Full Name of Surviving Spouse:
If Wife, Provide Maiden Name:
Company:
Residence - Street Address:
City/Town:
Inside City Limits:
County:
State:
Zip Code:
Length of Residence In County:
Father's Full Name:
Mother's Full Maiden Name:
Type of Disposition
Disposition Will Be:
If Cremation, Indicate Preference For Disposition of Ashes?:
Name of Cemetery (if applicable):
City:
State:
Preparation and Viewing
Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming.
Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.
The Family Preference Regarding Viewing/Embalming Is:
I Authorize CLIENT BUSINESS NAME To Embalm:
Name of Authorizing Person:
Relationship To Deceased:
Veteran Information
Was Decedent Ever In the US Armed Forces?:
Yes
No (if no, continue to next section)
Branch of Service:
Date Enlisted:
Date Discharged:
Honorable Discharge:
Yes
No
Military Serial Number:
Is A Copy of Discharge Papers Available?
Yes
No (if yes, please bring for us to copy)
Informant/Person In Charge Information
First Name:
Last Name:
Relationship To Deceased:
Email Address:
Address:
City:
State:
Zip Code:
Telephone Number:
Funeral/Memorial Service Information
Preferred Place of Service:
Religious Denomination:
Is there Immediate Need Funeral Insurance on decedent?
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