Good Shepherd Funeral Home
Vital Statistics/Death Certificate Information
1.Deceased's Name First, Middle, Last
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2.Sex
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3.Date of Death
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4.City and State or Country of Birth
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5.Age
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6.Date of Birth
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7.Social Security Number
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8a.Place of Death
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8b.Facility Name or Residence Street Address
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8c.City or Town of Death
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9a.Residence-State
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9b.County
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9c.City or Town
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9d.Street and Number
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9e.Apt. No.
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9f.Zip Code
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10a.Marital Status at Time of Death
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10b.Name of Spouse
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11.Father's Name
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12.Mother's Name
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13.Ever in U.S. Armed Forces & Service Dates
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14a.Informant Name
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14b.Relationship to Decedent
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15.Method of Disposition
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16c.Date of Burial or Cremation
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16d.Cemetery or Crematory, city and state
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