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If A Death Has Just Occurred

Death Certificate Information

Your Name

Your Phone Number

Your Email

Will You be Responsible for Making the Arrangements?

Who is this Plan for?

Name of Deceased

Place of Death (If Known)

Date of Death (If Known)

Your Relation to this Person?

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Vital Information

Gender

Date of Birth

City and State of Birth

Age

Race/Ethnicity

Hispanic Origin?

Social Security Number

Deceased's Legal Residence (No PO Boxes, Full Street Address, City, State, Zip)

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DECEASED'S OCCUPATION / EMPLOYER (before retirement) (Do Not Say Retired)

Usual Occupation (Job Title / Description)

Employer / Company Name & Location

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EDUCATION

Education/Highest Grade Completed

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MILITARY SERVICE

Was the Deceased a Veteran? ( Y / N )

Please Specify Years Served or War Time Period

If you have a copy of DD-214 / Honorable Discharge, please Upload Here

Upload File

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FAMILY INFORMATION

Deceased's Legal Marital Status

Surviving Spouse (PLEASE INCLUDE MAIDEN NAME, PRIOR TO MARRIAGE.)

Birth Name of Father/Parent

Birth Name of Mother/Parent (PLEASE INCLUDE MAIDEN NAME, PRIOR TO MARRIAGE.)

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INFORMANT's INFO (Next of Kin or Agent in Charge of Services)

Informant's Name

Informant's Mailing Address

Informant's Telephone

Informant's Email

How Many Death Certificates Do You Wish To Order?

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INFORMATION ABOUT THE DECEASED NEEDED FOR CREMATION

What is the Deceased's Estimated Weight?

Does the Deceased Have a Pacemaker or a Battery Powered Device Implanted?

Does the Deceased Have Any Jewelry or Personal Effects to be Returned?

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Death Certificate Form

If A Death Has Just Occurred

Death Certificate Information