INFORMATION FOR FILLING OUT DEATH CERTIFICATE

When you fill out the Death Certificate, it should provide a space for the name of the Funeral Director "or person acting as such." That's where you put your name. If the form does not look like this, put your name in the Funeral Director space and put your relationship to the deceased (e.g., "daughter") in the space that asks for the Funeral Director's license number.

1.  Decedent's name (First, Middle, Last)
2.  Sex of decedent
3.  Date of birth (Month, Day, Year)
4.  Age
5.  Date of Death (Month, Day, Year)
6.  Social security number
7.  Birthplace (City and State, or Foreign Country)
8.  County of death
9.  Place of death
10. City, town, or location of death
11. Marital Status
12. Surviving spouse (If wife, give maiden name)
13. Residence of decedent
14.  Residence--state, county, city, town, or location; street address
15. Occupation and industry of decedent
16. Decedent's race (Specify the race/races to indicate what the decedent considered himself/herself to be. More than one race can be specified)
17. Decedent's education
18. Was decedent ever in the U. S. Armed Forces?
19. Father's and mother's names (First, Middle, Last)
20. Informant's name, address, and relationship to the decedent
21. Place of disposition (name of cemetery, or other place) and location of
place of final disposition