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 all that apply)

Education Level


Family Information

Veteran's Information

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

Person responsible for making 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

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