Vital Statistics

Name of Deceased (Decedent):
Deceased (Decedent) Legal Address: (include apt. number, st, city, state, zipcode)
(Apt. number, st)
(City): (State): (Zip):
Date of Birth:
Place of Birth (City, State or Country)
Date of Death:
Place of Death: (City): (State):
Hospital or Nursing Home or Residence where person Died:
Social Security Number (if you do not know social security-enter all zeros):
Estimated weight (lbs.) of Decedent [Numbers Only, No Letters!]:
Occupation [Job they did when working]: (Do not enter “Retired”)
Type of Industry:
Highest Level of Education: (8th grade or less, 9-12 no diploma, H.S, Some College no degree, BA, MA, Ph.D, Unknown)
Gender: Male Female
Veteran: Branch of Service:
For NYC deaths, you must submit the original DD214 Honorable Discharge Paper in order to have veteran status on the death certificate.
Name of Spouse: (Including Maiden Name)
Marital Status: (Never Married, single, married, divorced, widow etc)
If legally married, spouse is next of kin and must sign.
Hispanic or non-Hispanic:
Race as defined by US census: White, Black or African American, other- Specify
Father’s Name: (First and Last Name)
Mother's Name: (First and Last include Maiden Name)
Next of Kin: Relationship:
Next of Kin Legal Address: (include apt. number, st, city, state, zipcode)
(Apt. number, st)
(City): (State): (Zip):
Home#: Cell Phone:
Email:

If you are done filling data into all fields, please submit the form (once submitted information can not be edited)

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