Vital Statistics Information for the Death Certificate | Lake Erie Cremation and Funeral Services

Name of Decendent:

Sex:

Date of Death:

Time of Death:

Social Security Number:

Age:

Date of Birth:

Place of Birth:

Veteran Yes or No

Facility Name:

City, Location of Death:

Signing Doctor:

County Of Death:

Marital Status

Surviving Spouse:

If wife give Maiden Name:

Residence State:

County:

City:

Street Name:

Inside City Limits Yes or No

Zip Code:

Is Decedent of Hispanic Origin: Yes or No

Race:

Highest Level of Education Completed: 0-12 . College (1-4,5+)

Name of Decedent’s Father:

Name of Decedent’s Mother (Including Maiden Name):

Name of Informant (Person giving this information):

Mailing Address of Informant:

Relationship of Informant to Decedent:

Method of Disposition:

Burial

Cremation

Removal from State

Other

Place of Disposition:

Location (City, State):

Date of Disposition:

Informant Email Address:

Informant Phone Number:

VITAL STATISTIC INFORMATION