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Vital Statistics Form

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.

Vital Statistics Information

Full Legal Name of Deceased:

(if applicable)


Full Legal Name of Deceased's Mother:


Full Legal Name of Deceased's Father:



Full Legal Name of Spouse (if applicable):


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

Home Address of Deceased:


Name of Informant:

Home Address of Informant:


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