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