Vital Statistics Form

Vital Statistics Information

This form will be used to complete death certificate. All required items are identified with an asterisk. If you do not have the complete information, please type unknown in the field and we will get the information at a later time.

Full Legal Name of Deceased:

First Name (of deceased)

Middle Name (of deceased) First Name Last Name

Last Name (of deceased)

Maiden Name (of deceased) (if applicable)

Date of Birth (of deceased)

Date of Death (of deceased)

City of Birth (of deceased)

State / Country of Birth (of deceased)

Full Legal Name of Deceased's Mother:

First Name

Middle Name

Last Name

Full Legal Name of Deceased's Father:

First Name

Middle Name

Last Name

Social Security Number of Deceased

Marital Status

Full Legal Name of Spouse (if applicable):

First Name

Middle Name

Last Name

Occupation(DO NOT PUT RETIRED)

Industry

Did the decedent ever serve in the armed forces?

YesNo

If yes, what branch?

Do you have a copy of Military Honorable Discharge Papers?

YesNo

(If a Veteran)

Upload Honorable Discharge Papers (DD-214)(If a Veteran)

Ethnicity

Highest Level of Education

Home Address of Deceased:

Street

City

State/Province

ZIP/Postcode

Name of Informant:

First Name

Middle Name

Last Name

Home Phone

Email Address

Cell Phone

Relationship to Decedent

Home Address of Informant:

Street

City

State/Province

ZIP/Postcode

Number of Death Certificates Requested** Remember that there is no suggested number of death certificates. We recommend that you request a few extra copies in case something comes up.

I confirm I have read the contents of this form and that the above information that I have provided is correct and true. I do not hold the representatives of Levine Memorial Chapel responsible if this information is not correct.

I agree

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Levine Memorial Chapel
| 649 Washington Avenue
| Albany, NY 12206
| Tel: 1-518-438-1002
|

Levine Memorial Chapel
| 649 Washington Avenue
| Albany, NY 12206
| Tel: 1-518-438-1002
| Fax: 518 438-0379

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Vital Statistics Form

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1-518-438-1002

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