Vital Statistics

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(615) 549-0074

Deceased Vital Statistics for Death Certificate
Name of Deceased*
Prefix First Middle Last Suffix
Please provide your loved one’s name exactly the way you would like it listed on the Death Certificate.
Date of Birth
Month
Day
Year
Date of Death
Month
Day
Year
Gender
Country of Birth (If Applicable)
City of Birth
State of Birth
Deceased Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Residence Inside City Limits?*
- Yes
- No
County of the Deceased Home Address
Location of the deceased*

Location of your loved one for transportation into our care.
Place of Death
Other (please specify)
County of Death
Marital Status at Time of Death
Name of Surviving Spouse
First Last
Maiden Name of Surviving Spouse
Occupation (most of life)
Kind of Business/Industry
Father's Full Name
First Middle Last Suffix
Mother's Full Name
First Middle Last Suffix
Mother's Maiden Name
Education of the deceased
Deceased of Hispanic Origin?
- Yes
- No
Hispanic Origin
- Mexican, Mexican American, Chicano
- Puerto Rican
- Cuban
- Other Spanish/Hispanic/Latino
- Unknown
Please Enter the Hispanic Origin of the Deceased
Race
Information About the Person Completing This Form
First Name*
Last Name*
Phone*
Email (Important)*
What is your relationship to the deceased?*
Your relation to the deceased?
Address of the Person Planning
- Same as the deceased (provided above)
- Input new address
Your Address*
Street Address City State ZIP Code
County You Are Located In*
Veteran Information
Was Decedent Ever In the US Armed Forces?
Branch of Service
Additional Information and Instructions
Does the Deceased have any type of implanted mechanical devices such as a Pacemaker, Steel Rods, Pins, Radioactive Devices, or other devices we should be aware of?*
- Yes
- No
Please list any type of implanted devices*
Photo of the deceased
Max. file size: 50 MB.
Please list any other instruction or information you would like us to have
Email
This field is for validation purposes and should be left unchanged.

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Vital Statistics

Deceased Vital Statistics for Death Certificate

Information About the Person Completing This Form

Veteran Information

Additional Information and Instructions