Demographic Data Form-center

1. Name of Deceased
2. Place of death
3. TEL:
4. TIME:
7A. State:
7B. COUNTY:
7C. CITY OR TOWN:
7D. STREET AND NUMBER:
APT NO:
ZIP CODE:
7E. INSIDE CITY LIMITS:
YES
NO
8. DOB (Month):
DOB (Day):
DOB (Year):
9. AGE AT LAST BIRTHDAY:
UNDER 1 YEAR:
UNDER 1 DAY:
10. SOCIAL SECURITY NO:
11a. Usual Occupation:
11b. Kind of Business or Industry:
12. Aliases or AKA’s:
13A. Birthplace_City:
13B. Birthplace_State:
13C. Birthplace_Foreign_Country:
14. Education (Check the box that best describes the highest degree or level of school completed at the time of death):
1. 8th Grade or less
2. 9th-12th grade; no diploma
3. High school graduate or GED
4. Some college credit; no degree
5. Associate degree (e.g. AA, AS)
6. Bachelor’s degree (e.g. BS, BA, BFA)
7. Master’s degree (e.g. MA, MS, MED, MSW, MBA)
8. Doctorates (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB)
15. Ever in U.S. Armed Forces:
YES
NO
16. Marital status at Time of Death:
1. Married
2. Divorced
3. Married but separated
4. Never Married
5. Widowed
6. Unknown
17. Surviving Spouse’s Name (if wife, name prior to first marriage):
18. Father’s Name (first, middle, last):
19. Mother’s Maiden Name (Prior to first marriage) (first, middle, last):
20a. Informant’s Name:
20b. Relationship to Descendant:
20c. Address (Street and number):
APT NO:
City:
State:
ZIP:
21a. Method of Disposition:
Burial
21b. Place of Disposition (Name of cemetery):
21c. Location of Disposition (City):
21c. Location of Disposition (State):
21c. Location of Disposition (Foreign Country):
21d. Date of Disposition:
Submit