"*" indicates required fields Step 1 of 3 33% Decedent's Full Name* Date of Death* MM slash DD slash YYYY County of Death* Address of Death Location* Street Address City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* MM slash DD slash YYYY City and State of Birth* Please enter both the city and state for our records. This next information is necessary for the Death CertificateDecedent's Social Security* Gender* Male Female US Veteran?* Yes No Unknown Highest Level of Education8th grade or less9th - 12th grade no diplomahigh school graduate or GED completedSome College credit but no degreeAssociate 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)Decedent's Race*WhiteBlack or African AmericanHispanic LatinoAmerican Indian or Alaskan NativeAsianNative HawaiianMarital Status*MarriedMarried, but separatedWidowedDivorcedNever MarriedUnknownSpouses Full MAIDEN Name (First, M, Last) Decedent's Address* Street Address City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is the address within city limits?* YES NO Estimated length of residence? (specify years or months)* Usual Occupation While Working Industry of Occupation Father's Name Prefix First Last Suffix Mother's Name (Maiden) Prefix First Last Suffix Informant's Name Prefix First Last Suffix Relationship to Decedent Next of Kin's Phone Number*Informant's Mailing Address Street Address City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Where did death occur?*Place of deathHospitalHospice FacilityDecedent's HomeNursing Home/Long-Term FacilityOtherFacility Name (if not a facility, give number and street)* Facility location* Street Address City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
