Vital Statistics

Name of Deceased:

Social Security Number:

Date of Birth:

Birthplace:

Address:

City Limits:

City:

State:

Zip:

Parish/County:

Sex:

Race:

Marital Status:

New Field:

U.S. Citizen:

Usual Occupation:

Industry:

Veteran:

Yes

Branch (If Applicable):

Rank:

Service Number:

Date of Death:

Time of Death:

Age:

Place of Death:

City Limits:

Name of Cemetery:

City:

State/Zip:

Parish/County:

Date of Burial:

Death Certificate Signed By:

Doctor's Phone and/or Email:

New Field:

Father's Birthplace:

Mother's Name:

New Field:

Spouse's Name (For Wife, Include Maiden Name):

Informant's Name and Relationship:

Email Address:

Address:

Phone Number:

City:

State:

Zip:

New Field:

Additional Relative:

Phone Number:

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Vital Statistics﻿