Page 31 - Hospice Savannah
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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:.............................................................................................................................................................................................. Address: ......................................................................................................................................................................................................... Birthplace: .................................................................................................................................................................................................... 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:.................................... Name of father:......................................................................................................................................................................................... Birthplace: ................................................................................................................................................... Date:.................................... Mother’s maiden name: ..................................................................................................................................................................... Birthplace: ................................................................................................................................................... Date:....................................
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