Name of Decedent:

AKA

Date of Birth

Date of Death

Sex
—Please choose an option—MaleFemaleOther

Birth State:

Armed Forces
—Please choose an option—YesNo

Marital Status:

Education:

Was Decedent Spanish/ Hispanic/Latino?
YesNo

Unusial Occupation:

Years in Occupation:

Decedent’s Address:

Decedent’s Address Line 2:

City:

Region:

Postal/ Zip Code:

Country:

Years in Country:

Informant's Name:

Relationship:

Informant's Address:

Informant's Address Line 2:

City:

Region:

Postal/ Zip Code:

Country:

Informant's Cell Phone:

Email

Decision Maker if Different from Informant & Relationship:

Name of Surviving Spouse: First, Middle, Last (Maiden):

Name of Father:

Name of Mother:

Father's Birth State:

Mother's Birth State:

Final Place of Disposition

Place of Death:

Place of Death Adress:

Place of Death Address Line 2:

Place of Death City:

Place of Death Region:

Place of Death Postal/ Zip Code:

Place of Death Country:

If Coroner (Case#) AND COUNTY:

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