Page 43 - Heritage Life Story - MI
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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 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: ..................................................................................................................................
Birthplace: ....................................................................................................... Date: ......................... City State Country
Mother’s maiden name: .......................................................................................................................
Birthplace: ....................................................................................................... Date: ......................... City State Country
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