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Death Certificate Worksheet Form

Death Certificate Worksheet

Click on the graphic on the left to download the file.

Death Certifcate Worksheet

This information will be used to complete the official death certificate form. This worksheet is not to be forwarded to the Office of Vital Statistics.

DECEDENT’S LEGAL NAME (First, Middle, Last)

SEX

SOCIAL SECURITY NUMBER

AGE-Last Birthday (Years)

DATE OF DEATH (Month, Day, Year)

DATE OF BIRTH

AGE-UNDER 1 YEARMonth/Days

AGE-UNDER 1 DAYHours/Minutes

PLACE OF BIRTH (City and State or Foreign Country)

WAS DECEDENT EVER IN U.S. ARMED FORCES?

YesNoUnknown

PLACE OF DEATH (Check only one)

HOSPITAL

Inpatient

ER/Outpatient

DOA

Place of Death

Nursing Home

Decedent's Residence

Hospice Facility

Other (Specify)

Assisted Living Facility

FACILITY NAME (If not institution, give street and number)

COUNTY OF DEATH

CITY OR TOWN OF DEATH

ZIP CODE

MARITAL STATUS

Married

Married, but separated

Widowed

Divorced

Never Married

SURVIVING SPOUSE If wife, give name before first marriage

Street

City

State/Province

ZIP/Postcode

INSIDE CITY LIMITS?

YesNo

FATHER’S NAME (First, Middle, Last)

MOTHER’S NAME Maiden Name (First, Middle, Last)

INFORMANT’S NAME First, Middle, Last

MAILING ADDRESS Street and Number, City, State, Zip Code

RELATIONSHIP TO DECEDENT

METHOD OF DISPOSITION

BurialDonationCremationEntombmentRemoval from StateOther (specify)

METHOD OF DISPOSITION - Other

ANCESTRYWhat is this person’s ancestry or ethnic origin? Italian, German, Dominican, Vietnamese, Hmong, French Canadian, etc. (Specify)

HISPANIC ORIGIN

No, not Spanish/Hispanic/Latino

Yes, Mexican, Mexican American, Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, Central American

Yes, South American

Yes, other Spanish/Hispanic/Latino

Unknown

Check the box or boxes that best describes whether the decedent is Spanish/Hispanic/Latino. Check the “no” box if the decedent is not Spanish/Hispanic/Latino

RACE

White

Black or African American

American Indian or Alaska Native (Name of the enrolled or principal tribes)

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Other

Unknown

Check one or more boxes to indicate what race(s) the decedent considered himself or herself to be.

EDUCATION

8th grade or less

9th - 12th grade; no diploma

High school graduate or GED

Some College credit, but no degree

Associate degree (e.g., AA, AS)

Bachelor’s degree (e.g., BA, AB, BS)

Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Unknown

Check the box that best describes the highest degree or level of school completed at the time of death

DECEDENT’S USUAL OCCUPATIONGive kind of work done during most working life. Do not use retired

KIND OF BUSINESS/INDUSTRYDo not give name of company.

In this section

Death Certificates Information

Funeral Payment Policy

Cremation Authorization Form

Assignment Of Rights

M.E. Northside Forms

Northside - Release Form

Northside - Photo Release Form

Northside - Record of Identification

M.E. Southside Forms

Southside - Release Form

Southside - Photo Release Form

Southside - Record of Identification

Death Certificate Worksheet Form

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