Vital Statistics FormContact PersonName*FirstMiddleLastAddress*Street AddressCityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeEmailPhone*Cell PhoneWork PhoneSocial Security NumberThe SSN is required to complete the arrangements. If you don't feel comfortable entering the information here, we will call you by telephone to retrieve the SSN.Relationship to Deceased*Deceased Person InformationDecedent's Name*FirstMiddleLastSuffixAliasesDecedent's AddressStreet AddressCityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeGender*MaleFemaleDate of Death*Date Format: MM slash DD slash YYYYDate of Birth*Date Format: MM slash DD slash YYYYPlace of Death*HospitalInstitution other than a HospitalDecedent's Home (address above)If Death Occurred in a Hospital*InpatientEmergency Room/OutpatientDead on ArrivalIf Death Occurred Somewhere Other Than a Hospital*Hospice FacilityNursing Home/Long-Term Care FacilityOtherName of Institution*Other (Specify)*Birthplace: City, County, State, Country*Social Security NumberThe SSN is required to complete the arrangements. If you don't feel comfortable entering the information here, we will call you by telephone to retrieve the SSN.Veteran?*YesNoVeterans are entitled to free death certificates. In order to apply for these, we need a copy of the DD214. Either scan the document into the computer or take a legible digital picture and upload the file below. Please be aware that free death certificates will take approximately 1-2 months to receive. If you need death certificates faster than we suggest you purchase them at $20/copy.Photo or scan of DD214If you cannot upload an image of the DD214 at this time, please email it to us later at adfh1@comcast.netDeceased Mailing AddressAddressStreet AddressApartment # or Suite #City, Township, or BoroughStateZip CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDid the deceased live in a Township?YesNoPlease list the name of the Township*Family MembersLegal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.Marital Status*MarriedNever MarriedWidowedDivorcedName of Spouse (maiden name, if wife)FirstMiddleLastMaidenBiological Father's Name*FirstMiddleLastBiological Mother's Name*FirstMiddleLastMaidenDecedent AttributesUsual Occupation*Kind of Business/Industry*Elementary & Primary Education (select highest completed)*123456789101112Higher Education*NoneSome College CreditAssociates DegreeBachelors DegreeMasters DegreeDoctorateHispanic?*No, not Spanish/Hispanic/LatinoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/LatinoOther Hispanic, SpecifyRace*WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawaiianGuamanian or ChamorroSamoanOther Pacific IslanderDon’t Know / Not SureRefusedOther (Specify)Other (Specify Here)Single Race Self Designation*WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawaiianGuamanian or ChamorroSamoanOther Pacific IslanderDon’t Know / Not SureRefusedOther (Specify)Other (Specify Here)