Vital Statistics | All County Cremation Services

Name

This field is for validation purposes and should be left unchanged.

Information About the Person Completing This Form

First Name*

Last Name*

Phone*

Email (Important)

Person for whom I am filling for:*

If not "Myself", your relation to the deceased.

Your Address*

Street Address City State ZIP Code

Phone*

Deceased Vital Statistics for Death Certificate

Location of the deceased*

Location of your loved one for transportation into our care.

Date of Death

Name of Deceased*

Prefix First Middle Last Suffix

City of Birth

State of Birth

Date of Birth

Gender

Marital Status at Time of Death

Name of Surviving Spouse

First Last

Father's Full Name

First Middle Last Suffix

Father's Birthplace

Mother's Full Name

First Middle Last Suffix

Mother's Maiden Name

Mother's Birthplace

Deceased's Address

Same as my own (provided above)
Input new address

Deceased Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Lived in County Since

Residence Inside City Limits?

Yes
No

Place of Death

Place of Final Disposition*

Name of Recipient*

First Last

Please give name and address of recipient.

Address of Family Residence*

Same as my own (provided above)
Input new address

Address of Family Residence*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of Recipient*

First Last

Please give name and address of recipient.

Address of Recipient*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of Cemetery*

Important! If the cremated remains are to be interred in a cemetery, we must know the name and address so that a burial permit can be provided.

Address of Cemetery*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Other (please specify)

Education

Occupation (most of life)

Years in Occupation

Kind of Business/Industry

Deceased of Hispanic Origin?

Yes
No

Race

Veteran Information

Was Decedent Ever In the US Armed Forces?

Please list any other instruction or information you would like us to have

NOTE: Once this form is completed you will be contacted by an arranger to complete your arrangements.