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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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