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Personal Information of the decedent

We'll get started here on this page.  Everything below is information that is needed to complete the death certificate.  After the certificate is completed, then it will be submitted to the health department for approval, and then off to the physician for signature.

First, we will start with your loved one's name, and then move on through the different fields as information is needed
If you do not know a certain information, enter "Unk" and we'll try to figure that part out together

Decedent's Name

Decedent's Name

If your loved one has a legal name and went by another name,
you may enter their "Also know as" name in this box

Informant's Name

Your phone number does not go on the certificate.  We just need it so we may contact you for further arrangements.  You may leave this blank if we have your number already

Decedent's Date of Birth

Decedent's Gender

Born in what state?

Did the decedent serve in the armed forces?             If so, what branch?

For education, put the number of years the decedent attended if not a high school graduate.  Otherwise, enter "HS Graduate.  Or you can put Some College, AA or AS, BA or BS, MA or MS, or PHD

Decedent's Race

For race, the following are examples of what you can enter: Caucasian, Asian, Black, Native American, East Indian, Arabic, Chinese, Japanese, etc.

Check one

This next section is Usual Occupation. 
It is asking what the decedent's occupation was for most of their life.
Please do not put "Retired". 
If the decedent was a homemaker, then enter "Homemaker"

The next section is Kind of Business. You will enter the kind of business the decedent's occupation was for.  eg; grocery store, road construction, agriculture, law enforcement, hospital, self employed  etc.       
If the decedent was a homemaker, then enter "Own home"

For how many years did the decedent work in that occupation?

Decedent's Last Residence

Informant's Mailing Address

Name of decedent's surviving spouse

Enter First , Middle, and Last name if there is a surviving spouse. 
If the surviving spouse is a wife, enter wife's maiden name
If the decedent is widowed, type "N/A"
If the decedent is divorced, type a "N/A"

Decedent's parents information

For father: enter first name, middle name, and last name and what state he was born in

For mother: enter first name, middle name, and maiden name and what state she was born in

Note: If a parent was born outside of the United States, please enter the country they were born in

Place of final disposition for the cremated remains

For this next section, we will need to know where you plan on keeping your loved one's cremated remains.  Your choices will be to have them buried in a cemetery, kept at a home of your choice, or they may scattered at sea (the law states that if scattered at sea, they must be scattered 500 yards off the coast line, and cannot be scattered from a bridge or a pier)

Check one

Please enter the place of final disposition of the cremated remains.  Enter the home address if the cremated remains will be kept at a home.  If they are to be buried, enter the name and address of the cemetery.  If the remains are to be scattered at sea, enter the city and state of the coast they are to be scattered.  

This completes the Personal Information section for the death certificate.  
To submit the information to us, click on the "Submit" button below.
We will collect the medical information from the attending physician or coroner.

Thank you

The content has been submitted

Please make sure all the red boxes are filled in

And then click Submit again

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