First Name, Middle Initial, Last Name:
Gender:
Date of Death:
Social Security Number:
Age:
Date of Birth:
Approximate Weight:
City and State of Birth:
Military?
Occupation:
Industry:
Descendant’s Full Address:
In The City Limits?
Hispanic Origin? If not, please specify race:
Years Education:
Father’s Name:
Mother’s Name:
Place of Death (Resident, Hos. Inpatient, Hospice, Er/Outpatient, or Other):
Facility Name:
City:
State:
County:
Zip:
Marital Status:
Informant’s Name:
Relationship To Deceased:
Full Address:
Telephone:
Email:
Primary Doctor Name:
Doctor Address:
Doctor Phone:
Time of Death (Include AM/PM):
Was There An Autopsy?
Did Tobacco Contribute To Death?
If Female, was the deceased…
Not Pregnant within the last year?
Pregnant at Time of Death?
Pregnant within 42 days of death?
Pregnant Within 43 to 365 days prior?
Unknown if Pregnant within last year:
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