Deceased's Name
First,
Middle, Last
Date of Death
Month,
Day, Year
Sex
Date of Birth
Month,
Day, Year
Name at Birth
(Including AKA if any)
Birthplace City and State or Country
Father's Name
Mother's Name before first
married
First,
Middle, Last
Race
Ancestry
English,
French, Finnish, etc. Enter all
that apply.
Deceased's Current Residence
Street and Number
Including Apt. No. if Applicable
Locality
(also
check type of locality) CITY
TOWNSHIP
UNINCORPORATED
PLACE
State
County
Zip Code
Deceased's
History
Education
What is
the highest degree or level of
school completed at the time of
death?
U.S. Armed Forces?
Was
Decedent Ever In the U.S. Armed
Forces? (Yes or No)
Occupation
Type of work done during most of
working life. Do not use
retired.
Type of Business or Industry
Marital Status
Married, Never Married, Widowed,
Divorced (specify)
Date of Marriage
Place of Marriage
Name of Surviving Spouse
If
wife, give name before first married
Surviving Children (and Spouses)
Surviving Grandchildren
Surviving Sisters
Surviving Brothers
Funeral/Service Plans:
Burial or Cremation
Please Select
Burial
Cremation
Cemetery Preference
Location
City or
Village, State
Clergy Request
Pallbearers
Songs
Memorials/Donations To
Funeral/Service Plans:
Your Name
Relationship to
Deceased
Mailing Address
Street
and number, City or Village, State,
Zip Code
Your Phone Number
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