Vital Statistics Form

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BASIC STATISTICS

Name:

A Death Has Occurred

Death is Imminent

Planning Ahead

Person's Legal Name (first, middle, last, suffix)

Aliases or AKAs (other names by which person is known)

If Death Has Occurred or is Imminent, Specify Facility and/or address of the individual

Date of Death (if applicable)

Time of Death (AM/PM)

Sex

Legal Address

City

State

Zip Code

County

Inside City Limits

Yes

No

Date of Birth

Age at Last Birthday

Social Security Number

Usual Occupation (do not enter retired)

Kind of Business or Industry

Education (the highest level of school or degree completed at time of death)

8th grade or less; none

9th-12th grade; no diploma

High school graduate or GED

Some college credit, but no degree

Associates Degree

Bachelor's Degree

Master's Degree

Doctorate Degree or Professional Degree

Ever in U.S. Armed Forces

Yes

No

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(If requesting military honors, please email us DD214 or Separation Papers)

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FAMILY INFORMATION

Marital Status

Surviving Spouse/Partner (name prior to first marriage: first, middle, last)

Father's Name (first, middle, last)

Mother's Name (name prior to marriage; first, middle, last)

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INFORMANT INFORMATION

Primary Informant's Name (person to be listed on the death certificate)

Relationship

Address

City

State

Zip Code

County

Primary Informant's Contact Email

Primary Informant's Contact Phone Number

Secondary Informant's Name

Relationship

Address

City

State

Zip Code

County

Secondary Informant's Contact Email

Secondary Informant's Contact Phone Number

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FINAL DIPOSITION

Method of Disposition

Burial

Cremation

Entombment

Undecided/Other

Place of Disposition (name of cemetery, crematory or other)

Location of Disposition (city and state or foreign country)

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Kleinberg Funeral Services will contact your cemetery to verify grave location. Please provide us with as much information as possible:

• Name(s) of previous burial(s) with approximate date(s)

• Who owns the grave(s)?

• Private or society grounds?

• Location (e.g. contract/map #, section, block, lot, row, division, path, grave)

• If you need to purchase a grave

New Field:

Please enter any other information we may find helpful

VITAL STATISTICS FORM