First:required *
Middle:
Last:required *
Last name prior to first marriage: (if applicable) ?
Sex:required *(according to official records) Select sex: Male Female
Age at last birthday:required *
County and state of birth:
County:
State: Please select: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington, D.C. Other/Foreign Country (please specify)
If other or foreign country, please specify:
Date of birth:required *
Marital Statusrequired * Please select: Married Separated Divorced Never married Widowed Unknown
Spouse's name (if wife, use maiden name):
Individual's usual occupation (do not use retired or disabled):If retired or disabled, please list last occupation before retirement or disability. ?required *
Kind of business/industry:required *
Social Security Numberrequired *
Individual's residence:
Residence-State or Foreign Country: Please select: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington, D.C. Other/Foreign Country (please specify)
If foreign country, please specify:
County:required *
Street and number:required *
City:required *
Zip Code:required *
Is the residence within city limits?required * Please select: Yes No
Background:
Was the individual ever in the U.S. Armed Forces?required * Please select: Yes No
If yes, is a copy of the individual's military discharge papers available? If applicable, please select: Yes No
Education completed:(the highest degree or level of school completed by individual) ? Please select: 8th grade or less 9th-12th grade; no diploma High school graduate or GED completed Some college credit, but no degree Associate degree Bachelor's degree Master's degree Doctorate or Professional degree
Individual's Race:(if multiple, please specify below) ? Please select: Black or African American White Hispanic Other (please specify)
Please specify if necessary:
Individual's father's full legal name: First:required *
Middle:
Last:required *
Email address:
Email address of the person submitting this form:required *
Point of contact after death:
Name of primary point of contact after the death:required *
Contact's relationship to individual:required *
Contact's address:
Street and number:required *
City:required *
State: Please select: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington, D.C.
Zip Code:required *
Contact's telephone number:required *
Additional questions: Is the individual currently under hospice care?required * Please select: Yes No
Name of hospice provider:(if yes) ?
Did the individual have a pacemaker?required * Please select: Yes No
Three (3) Certified Death Certificates are already included. Please note any additional certificates needed here.
Death certificates requested:(each additional certificate after the first three costs $15) ?required *
3 certificates included + = 3 total death certificates.
