Statistical Information

Please Select One

Name (First – Middle – Last):

Complete Street Address:

Date of Birth:

Place of Birth (City, State):

Social Security Number:

U.S. Veteran:

Yes

If Yes, Name of War & Dates Served:

Father’s Name:

Mother’s Name (first & maiden name - name on birth certificate):

Marital Status of the person you are making arrangements for. (Please select one):

If Applicable, Name of Surviving Spouse (first & maiden name - name on birth certificate)

Highest Level of Education Completed (Please select one):

Decedent of Hispanic Origin?

Yes

No, Not Spanish/Hispanic/Latino

If yes, please specify:

Decedent Race:

White

Black or African American

Other Race, please specify:

Occupation of Deceased (Type of work done most of life, retired is not an option):

Industry:

Last Employer:

Free Text

Informant or Next of Kin Information

Informant’s Name:

New Field:

Relationship to person the arrangements are for (Please select one):

If relationship is not listed, please specify:

Email Address:

Phone Number:

Complete Mailing Address:

Statistical Information Form