vital-template | Stevens Mortuary Inc

Full Legal Name:

List Name In Obituary This Way:

Address:

City:

State:

Zip:

Home Phone Number:

Live in City Limits: Yes No

County:

Date of Death:

Hour:

Place:

Day:

Date of Birth:

Age:

Social Security No:

Place of Birth: (City)

Place of Birth: (County)

Place of Birth: (State)

Decedent's Education (Select the from the options the highest degree or level of school completed at the time of death) 8th grade or less 9th to 12th grade; no diploma High school graduate or GED completed Some college credit, but no degree Associate degree (e.g., AA, AS) Bachelor's degree (e.g., BA, AB, AS) Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) Unknown

Decedent's of Hispanic Origin? (Select from the options that best describes whether the decedent is Spanish/ Hispanic/ Latino.) No, not Spanish/ Hispanic/ Latino Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, other Spanish/ Hispanic/ Latino Unknown

If decedent is other than Spanish/ Hispanic/ Latino origin, please specify.

Decedent's Race (Select the race/s to indicate what the decedent considered himself or herself to be) White Black or African American American Indian or Alaskan Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other Unknown

If American Indian or Alaskan Native, please indicate the name of the enrolled or principal tribe.

if Other Asian race, please specify.

If Other Pacific Islander race, please specify.

If other than the races indicated above, please specify.

Civil Status: Single
Married
Widowed
Divorced

Occupation: (Type of work done)

Employed By: (If self-employed, name of company)

Husband or Wife: (If wife, give first, middle, and maiden name)

Name:

Address:

City:

State:

Date of Birth:

Social Security No:

Phone: (Residence)

Phone: (Work)

Father's Name: (First, Middle, Last)

Mother's Name: (First, Middle, Maiden)

Veteran: Yes No

Branch of Service:

War Served:

Physician: (Who will sign death certificate)

Phone:

Mailing Address:

City:

State:

Informant's Name:

E-mail:

Address:

City:

State:

Zip:

Phone Number: (Mobile)

Phone Number: (Home)

Phone Number: (Work)

Church Affiliation:

Other Organizations or remarks:

Memorials:

Preceded in death by:

Survivors – list city and/or state where they live:

Wife or Husband:

Daughter(s) and Son(s)-in-law:

Son(s) and Daughter(s)-in-law:

Parents:

Grandchildren:

Great Grandchildren:

Sister(s) and Brother(s)-in-law:

Brother(s) and Sister(s)-in-law:

Other:

Place of Service:

Hour:

Day:

Minister(s):

Cemetery:

Location:

Day of Graveside Service:

Time of Graveside Service:

Pallbearers:

Receive Friends: (Day)

Receive Friends: (Time)

Newspaper Notice: (When/where to place)

Secret Question

Vital Statistic & Obituary Form

Vital Statistics and Historical Data Form

Filing Decedent's Insurance: Beneficiary's Information

Obituary Information

Survivors – list city and/or state where they live: