Vital Records Worksheet

(print only)ME# ___-_________DOD__________TOD__________am--pm

Decedents Name:__________________________________________________Age___

AKA/Other Name/Maiden_________________________________________________

Male_Female_DOB_______SS#_____-___-_____Birthplace_____________________

Place of Death________________City/State_________________County___________

Residence/City______________________State__ZIP_____County________________

Race____________Ancestory___________Hispanic Origin_ Education Level______

Arm Forces Served: yes/no - Which Branch Served___________Marital Status____

Name of Surviving Spouse_______________________DOB______SS#___-__-______

Surviving Spouse Address(if different)_______________________________________

Usual Occupation__________________Kind of Business________________________

Fathers Name____________________Mothers/Maiden________________________

InformantsName____________________________Relationship_________________

Informants
Address___________________________City/State/ZIP_________________________

Phone(___)________________Cell(___)_____________Email____________________

Method of Disposition_____________Place___________________________________

Information Approved by:_______________________________________

Name of Doctor:________________________________________________