Vital Statistics Form

One of the most important documents to the survivors of loss is the Death Certificate, as it is required by the Social Security Administration, insurance companies, and the many other legal matters which follow someone’s death. The Vital Statistics Form below provides us with much of what we’ll need to complete this document on your behalf. Please be sure all information and spelling of names are correct.


Personal Information

Race (check one or more)

Education (choose one)


Other occupations or places of employment for obituary:

Family Information

Other information for obituary (schools attended, dates of high schoole/college graduation, hobbies, church affiliations, club memberships, fraternal organizations):

Veteran's Information

(We will need a copy of DD-214's for military benefits)

Person responsible for making the funeral arrangements

Family Members

Please list SURVIVING family members below - name, relationship to deceased, city and state where they currently live (ex. spouse, children, parents, grandparents, brothers, sisters, grandchildren, great-grandchildren, great-great-grandchildren)

PREDECEASED by the following family members (name and relationship to deceased)

Service Information

Honorary Pallbearers