Vital Statistics Form

Referred By:
Vital Statistics Form
This form must be typed or printed clearly.
Name of Beneficiary:*
First Middle Last
Beneficiary Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
SSN*
Age*
Date of birth:*
MM slash DD slash YYYY
Sex:*
Armed Forces:*
- Yes
- No
Birthplace*
City State / Province / Region Country
Occupation: (Do not use Retired)*
Business: (Type of business, eg. factory, manufacturer)*
Marital Status:*
Spouse: (if wife, give maiden name)*
Decedent of Hispanic Or Haitian Origin?*
- No - Not of Hispanic/Haitian Origin
- Unknown if Hispanic/Haitian Origin
- Yes, of Hispanic/Haitian Origin (Select One Below)
If Yes, Of Hispanic/Haitian Origin (Select One)
- Haitian
- Mexican
- Puerto Rican
- Cuban
- Other Hispanic (Specify Below)
Other Hispanic
Race:*

(Do not use hispanic)
Education:*
Father's Name:*
First Middle Last
Mother's Name:*
First Middle Last
Next of Kin/Informant's Name:*
Next of Kin/Informant's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Next of Kin/Informant's Phone:*
Relationship:*
This form is used to complete the death certificate, which is a legal document and filed with the
State of Florida. It is therefore important to fill completely and accurately with the proper spelling
of names and places. Corrections to the death certificates require 6 to 8 weeks and there are fees
that apply.

I certify that to the best of my knowledge that all information is true and correct.
Signature of person completing form*

Cremation Forms – Pre-Planning

Necessary Forms: Pre-Planning

Step 1 of 3

CLOTHING RELEASE

CREMATION SOCIETY OF AMERICA