Zipperer's

Zipperer's
Funeral Home

Vital Statistical Information

The following information is needed to complete the death certificate at one's time of need or when making pre-arrangements.

Name: First Middle: Last:

Date of Birth: (Month, Day, Year) Age: Date of Death:

Social Security Number: Birth Place: (City) State:

County of Death: Place of Death:

City / Town of Death: Inside City Limits?

Marital Status: Married Married, but Separated Widowed Divorced Never Married

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

Residence - State: County: City / Town:

Street Address: Apt #:

Inside City Limits ?

Decedent's Usual Occupation (Indicate type of work done most of working life)

Do not use " retired"

Kind of Business / Industry:

Decedent's Race: (Specify the race / races to indicate what decedent concidered himself herself to be. More than one may be used.

White Black or African American American Indian or Alaskan Native ( Specify tribe)

Asian Indian Chinese Filipino Japanese Korean Vietnamese

Other Asian ( Specify) Native Hawaiian Guamanian or Chamorro

Samoan Other Pacific Island ( specify ) Other

Decedent of Hispanic or Haitian Origin ? (If Yes, specify) Mexican Puerto Rican

Cuban Central / South American Other Hispanic (Specify) Haitian

Decedent's Education: (Specify the highest or level of school completed at time of death.)

8th or less High School but no diploma High school diploma or GED College but no degree

College degree (Specify): Associate Bachelor's Master's Doctorate

Was Decedent Ever in the U.S. Armed Forces ? Branch of Service:

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

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

INFORMANT'S INFORMATION

Informant's Name: (Person giving this information)

Informant's e-mail Address:

Relationship to Decedent: Informant's Mailing State:

City / Town: Street Address:

Zip Code:

DISPOSITION

Method of Disposition: Burial (Specify Cemetery Location) City: State:

Cremation Removal from State Anitomical Donation