Plan
Obituaries
Resources
Why Plan Online?
Burial Options
FAQs
Family Pay
Social Security Benefits
Forms
Pricing Options
Urn Selections
About
Why Anderson Simple Cremations?
Our Guarantee
Service Areas
Contact
(864) 642-6655
|
Cart
Plan
Obituaries
Resources
Why Plan Online?
Burial Options
FAQs
Family Pay
Social Security Benefits
Forms
Pricing Options
Urn Selections
About
Why Anderson Simple Cremations?
Our Guarantee
Service Areas
Contact
Vital Statistics Form
Please fill out the following form to provide vital statistics for certified death certificates.
Deceased Vital Statistics for Death Certificate
Name of the Deceased
*
First
Middle
Last
Suffix
Gender
*
Please Choose...
Male
Female
Date of Birth
*
MM
DD
YYYY
Date of Death
*
MM
DD
YYYY
Deceased Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
County of the Deceased Home Address
*
Residence Inside City Limits?
*
Yes
No
Country of Birth
*
City of Birth
*
State of Birth
*
Please Choose...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Other
Place of Death
*
Please Choose...
Hospital - Inpatient
Hospital - Emergency Room
Residence
Nursing Home/Assisted Living Facility
Hospice Facility
Other (please specify)
Other (please specify)
*
Location of the Deceased
*
Location of your loved one for transportation into our care.
County of Death
*
Veteran Information
Was Decedent Ever In the US Armed Forces?
*
Please Choose
Yes
No
Branch of Service
*
Marital & Family Information
Marital Status at Time of Death
*
Please Choose...
Married
Never Married
Widow
Widower
Divorced
Name of Surviving Spouse
*
First
Last
Maiden Name of Surviving Spouse
*
Father's Full Name
*
First
Middle
Last
Suffix
Is the father of the decedent living or deceased?
*
Please Choose...
Living
Deceased
Mother's Full Name
*
First
Middle
Last
Suffix
Mother's Maiden Name
*
Is the mother of the decedent living or deceased?
*
Please Choose...
Living
Deceased
Does the decedent have living children over the age of 18?
*
Please Choose...
No living children over the age of 18
1 Living child over the age of 18
2 Living children over the age of 18
3 Living children over the age of 18
4 Living children over the age of 18
5 Living children over the age of 18
6 Living children over the age of 18
7 Living children over the age of 18
8 Living children over the age of 18
Child 1
*
First Name
Last Name
Child 2
*
First Name
Last Name
Child 3
*
First Name
Last Name
Child 4
*
First Name
Last Name
Child 5
*
First Name
Last Name
Child 6
*
First Name
Last Name
Child 7
*
First Name
Last Name
Child 8
*
First Name
Last Name
Race & Ethnicity of Decedent
Deceased of Hispanic Origin?
*
Yes
No
Hispanic Origin
*
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Other Spanish/Hispanic/Latino
Unknown
Please Enter the Hispanic Origin of the Deceased
*
Race of Decedent
*
Please Choose...
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other
Name of the enrolled or principal tribe
*
Specify
*
Education & Occupation of Decedent
Education of the Deceased
*
Please Choose...
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
I Do Not Know at This Time
Kind of Business/Industry
*
Occupation (most of life)
*
Information About the Person Completing This Form
First Name
*
Last Name
*
Phone
*
Email (Important)
*
What is your relationship to the deceased?
*
Please Choose...
I am the spouse of the deceased
I am the parent of the deceased
I am the brother/sister of the deceased
I am the aunt/uncle of the deceased
Other
Your relation to the deceased?
Address of the Person Planning
*
Same as the deceased (provided above)
Input new address
Your Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County You Are Located In
*
Additional Information and Instructions
Does the deceased have any type of implanted mechanical devices such as a Pacemaker, Steel Rods, Pins, Radioactive Devices, or other devices we should be aware of?
*
Yes
No
Please list any type of implanted devices
*
Drivers License/Photo ID of person making arrangements
*
Please list any other instruction or information you would like us to have
Phone
This field is for validation purposes and should be left unchanged.
Plan Online
Merchandise