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.


First Name Last Name
(if applicable)






(DO NOT PUT RETIRED)
(If a Veteran)
(If a Veteran)





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

© 2022 Levine Memorial Chapel. All Rights Reserved. Funeral Home website by CFS & TA | Terms of Use | Privacy Policy