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Vital Statistics
The information below will be necessary for the preparation of a death certificate. The funeral director will record it and have certified copies made.
Date: .................................................................................... My full name: .....................................................................................................................................................................................
First Middle Maiden Last
Address: ..............................................................................................................................................................................................
City State Country
Birthplace: ..........................................................................................................................................................................................
City State Country
Birth date: ............................................................................................. Social security number: ................................................... Citizen of what country:..................................................................... Naturalization no.............................................................. Schools attended:................................................................................. From:........................To:.......................Degree:............... .............................................................................................................................................................................................................. .............................................................................................................................................................................................................. Number of years of formal education:............................................................................................................................................ Professional statistics
Company: ............................................................................................. Job title: .................... From:..................To: ....................... .............................................................................................................................................................................................................. .............................................................................................................................................................................................................. Professional achievements:............................................................................................................................................................... .............................................................................................................................................................................................................. If Veteran, name of war(s):............................................................................................................................................................... Date of service:................................................................................................................................................................................... Branch of service and rank:................................................................ Serial no. ............................................................................ Years residence established in this state:........................................... Years residence established in this community: ........... Marital status: Married Single Divorced Widowed
Date of marriage: ................................................................................. Name of Partner: .............................................................. Birthplace: .............................................................................................................................................Date:...................................
City State Country
Name of father: .................................................................................................................................................................................. Mother’s maiden name: ....................................................................................................................................................................
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