Vital Statistics Form

The information contained in the Vital Statistic form is used to complete the Death Certificate. It is imperative that all of the information provided is current and correct. If you are unsure of any portion of the online form, please leave blank and call the office once you have the correct information.

We have provided a convenient option to complete this form. You may fill it out and submit it online. By submitting this form online, you are authorizing ICS Cremation and Funeral Home to use the information you provide.

In the event that a mistake is made on a certified Death Certificate, it will be the responsiblity of the family to handle any costs associated with the amendment process.

Please fill out each section of this form accurately. If you have any uncertainty, leave it blank and call once you have the correct information.

Decedent's Name

Sex
 Male Female

Date of Birth

Birthplace (City and State or Foreign Country)

Marital Status

Surviving Spouse's Name (If wife, give maiden name)

Residential Address (Physical mailing address, including county)

Residence Inside the City Limits?
 Yes No

Decedent's Occupation

Kind of Business/Industry

Decedent's Race

Decedent's Education

Was Decedent ever in the U.S. Armed Forces?
 Yes No

Father's Name (First, Middle, Last)

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

Informant's Name (First, Middle, Last)

Relationship to Decedent (i.e. Father, Mother, Husband, Wife, Son, Daughter)

Informant's Complete Physical Address (Include county and zip code)

 

Person Providing Information

Relationship

Email Address

Phone Number

BY SUBMITTING THIS FORM I AGREE THAT THE INFORMATION IN THIS FORM IS TRUE AND CORRECT AND AUTHORIZE IT TO BE USED ON LEGAL DOCUMENTS.