Vital Statistics Form | Anderson Simple Cremations

Deceased Vital Statistics for Death Certificate

Name of the Deceased*

First Middle Last Suffix

Gender*

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 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*

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*

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.