Vital Statistics For Cremation Arrangement Vital Statistics For Cremation Arrangement CommentsThis field is for validation purposes and should be left unchanged.Decedent’s Legal Name(Required)(First, Middle, Last, Suffix)Sex Male Female Social Security Number(Required)Date of Death MM slash DD slash YYYY (M/D/Y)Date of Birth MM slash DD slash YYYY (M/D/Y)Age on Last BirthdayRESIDENCEAddress Residence Street Address Apt./Suite City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State/Province ZIP Code Inside City Limits?BIRTHPLACEAddress Birthplace City County AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State/Province Ever in U.S. Armed Forces? Yes No Marital Statius at time of death Married Married but separated Widowed Divorced Never Married Unknown Surviving Spouse’s Name(First, Middle, Maiden)Father’s Name(First, Middle, Maiden)Mother’s Name(First, Middle, Maiden)Informant’s Name(Required)Relationship to DecedentEmail(Required) Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Decedent’s EducationThat best describes the highest degree or level of school completed at the time of death. 8th grade or less. 9th - 12th grade, no diploma. High school graduate or GED completed. Some college credit, but no degree. Associate Degree (e.g. AA, AS) Bachelor’s Degree (e.g. BA, AB, BS) Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) Decedent of Hispanic Origin?Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the “No” box if decedent is not Spanish/Hispanic/Latino. No, not Spanish/Hispanic/Latino Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latino Yes, other Spanish/Hispanic/Latino (Specify)Decedent’s RaceDecedent considered himself or herself to be. Caucasian Black or African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other American Indian or Alaska Native (Name of the enrolled or principal tribe)Other Asian (Specify)Other Pacific Islander (Specify)Other (Specify)Decedent’s Usual OccupationIndicate type of work done during most of working life. DO NOT USE RETIRED.Kind of Business/IndustrySignature(Required)Number of Certified CopiesCAPTCHA
