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Frequently Asked Questions
Vital Statistics Form
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Full Name of Decedent
Sex
Male
Female
Date of Death
Time of Death
Age
Date of Birth
Place of Birth
Veteran?
Yes
No
Place of Death
Location
Hospital
ER/Outpatient
Nursing Home
Home
Facility Name
City, Location of Death
County of Death
Spouse
Marital Status
Surviving Spouse
Maiden Name (if applicable)
Residence
State
City
County
Street Number
Inside City Limits
Yes
No
Zip Code
Ethnicity
Is Decedent of Hispanic Origin
Yes
No
Race
Highest Level of Education Completed
Primary Education (0-12)
College (1-4, 5+)
Family
Name of Decedent's Father
Name of Decedent's Mother (Including Maiden Name)
Name of Person giving this information
Address
Apt, Suite, Etc.
Zip Code
City
State
Relationship to Decedent
Disposition
Method
Burial
Cremation
Removal from State
Other
Place of Disposition
City
State
Date of Dispostion
Submit
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