Vital Information Sheet
At our request, please fill out the Vital Statistical Information form and submit it automatically to us. This feature will allow you the option of filling out requested information in the convenience of your own home or office.
Last Name:
Middle Name:
First Name:
Phone
(with area code)
:
(
)
-
Address:
City:
State:
Zip:
County:
Years in County:
Date of Birth
(month, day, year)
:
Sex:
Male
Female
Veteran:
No
Yes - Branch:
Dates Served:
City and State of Birth:
,
Social Security Number:
Marital Status:
Married
Divorced
Widowed
Never Married
Race:
Usual Employer:
Type of Business:
Occupation:
Years in Occupation:
Name of Spouse:
First:
Middle:
Last:
Maiden Name:
Father’s Name:
First:
Middle:
Last:
State of Birth:
Mother’s Name:
First:
Middle:
Last:
Maiden Name:
State of Birth:
Informant:
(If self, please state)
Phone
(with area code)
:
(
)
-
Address:
City:
State:
Zip:
Today’s Date:
Cremation Options
(please check all that apply):
Direct Cremation
Cremation with Memorial Service
Witnessed Cremation
Cremation with Witnessed Placement at Sea
Priority Cremation
Full Traditional Service Followed by Cremation
Burial Options
(please check all that apply):
Immediate Burial
Graveside WITHOUT Visitation
Graveside WITH Visitation
Full Traditional Service
Immediate Family and Closest Friends:
Name
Relationship
Address
Phone