Vital Statistics Form - Anderson Simple Cremations

Deceased Vital Statistics for Death Certificate

Name of the Deceased*

First Middle Last Suffix

Gender*

Date of Birth*

Date of Death*

Deceased Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County of the Deceased Home Address*

Residence Inside City Limits?*

Yes
No

Country of Birth*

City of Birth*

State of Birth*

Place of Death*

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?*

Branch of Service*

Marital & Family Information

Marital Status at Time of Death*

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?*

Mother's Full Name*

First Middle Last Suffix

Mother's Maiden Name*

Is the mother of the decedent living or deceased?*

Does the decedent have 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*

Name of the enrolled or principal tribe*

Specify*

Education & Occupation of Decedent

Education of the Deceased*

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?*

Your relation to the deceased?

Address of the Person Planning*

Same as the deceased (provided above)
Input new address

Your Address*

Street Address City 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*

Max. file size: 50 MB.

Please list decedents Social Security Number here along with any other instruction or information you would like us to have

Comments

This field is for validation purposes and should be left unchanged.

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