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DECEDENT’S LEGAL NAME

Full Name

Confirm Full Name

First Name

Middle Name

Last Name

Suffix

Maiden Name

Sex

Age - Last Birthday

Under 1 Year

Months

Days

Under 1 Day

Hours

Minutes

Date of Birth

BirthplaceCounty/State/Foreign Country

Date of Death

PLACE OF DEATH (Check only one)

IF DEATH OCCURRED IN A HOSPITAL

Inpatient

ER/Outpatient

DOA

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL

Hospice facility

Nursing home/Long term care facility

Decedent’s home

Other (Specify below)

Other

FACILITY NAME (If not institution, give street and number)

CITY OR TOWN

COUNTY OF DEATH

MARITAL STATUS

SURVIVING SPOUSE Give name prior to first marriage

DECEDENT’S USUAL OCCUPATIONDo not use retired

KIND OF BUSINESS/INDUSTRY

SOCIAL SECURITY NUMBER

RESIDENCE–STATE OR FOREIGN COUNTRY

COUNTY

CITY OR TOWN

Street

City

State/Province

ZIP/Postcode

INSIDE CITY LIMITS

YesNo

WAS DECEDENT EVER IN U.S.ARMEDFORCES?

YesNo

DECEDENT’S EDUCATION

8th grade or less

9th–12th grade; no diploma

High school graduate or GED completed

Some college credit, but no degree

Associate degree (e.g., AA, AS)

Bachelor’s degree (e.g., BA, AB, BS)

Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

Doctorate (e.g., PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)

Check the box that best describes the highest degree or level of school completed at the time of death

DECEDENT OF HISPANIC ORIGIN?

No, not Spanish/Hispanic/Latino

Yes,Mexican,MexicanAmerican,Chicano  Yes, Puerto Rican

Yes,Cuban

Yes, other Spanish/Hispanic/Latino (Specify)

Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the “No” box if decedent is not Spanish/Hispanic/Latino

Specify

DECEDENT’S RACE

White

Black or African American

American Indian or Alaska

Native Name of the enrolled or principal tribe

Asian Indian

Japanese

Chinese

Korean

Filipino

Vietnamese

Native Hawaiian

Guamanian or Chamorro

Samoan

Other (Specify below)

Check one or more races to indicate what the decedent considered himself or herself to be

Specify

Parents

Father / Parent Name

First Name

Middle Name

Last Name

Mother / Parent Name

First Name

Middle Name

Maiden Name

INFORMANT

NAME

RELATIONSHIP TO DECEDENT

Street

City

State/Province

ZIP/Postcode

METHOD OF DISPOSITION

Burial

Cremation

Donation

Entombment

Removal from State

Other (Specify)

Other

PLACE OF DISPOSITIONNAME OF CEMETERY, CREMATORY, OTHER PLACE

LOCATION

Street

City

State/Province

ZIP/Postcode

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