death certificate information form

DEATH CERTIFICATE INFORMATION FORM Goundrey & Dewhirst Funeral Home 42 Main Street Salem, NH 03079 T: 603.898.2181

PLEASE BE SURE TO CHECK THE INFORMATION FOR ACCURACY. ANY CORRECTIONS AND/OR FEES ASSOCIATED WITH CORRECTIONS WILL BE THE RESPONSIBILITY OF THE PARTY PROVIDING THE INFORMATION.

First Name: Last Name: Middle Name: Sex: (m/f)

Date of Death: (MM/DD/YYYY)

Date of Birth:

Age (Yrs.):

Race:

(MM/DD/YYYY)

(Asian/Black/Hispanic/Native American/White)

Occupation (Last Known):

Last Known Employer:

Kind of Industry or Business: Place of Death: Address:

City:

State:

County:

Place of Birth: City:

State:

Country:

(If USA)

(If Foreign Birth Place)

Resident Address: Address:

City:

State:

Zip Code:

County:

Social Security #: U.S. War Veteran:

No

Yes

If Yes, documents must be provided.

Date & Place of Enlistment: Date & Place of Discharge: Rank: Branch of Service:

Service #:

Highest Grade Completed: (1/2/3/4/5/6/7/8/9/10/12)

Years of College: (1/2/3/4/5+)

Marital Status: (Married/Divorced/Widowed/Never Married)

Name of Last Spouse: (If Female, Provide Maiden Name)

Parents Information: Father’s Name: Father’s U.S. State or Foreign Country of Birth: Mother’s First Name and Maiden Name: Mother's U.S. State or Foreign Country of Birth: Mother’s Legal Name (As It Would Appear on a Legal Document): Informant: (Person Responsible for Making Arrangements)

Full Name: Address: (City, State, Zip)

Relationship to Deceased: Primary Phone Number: Alternate Phone Number: Email: Additional Notes:

Please Print and Fax Form to 978-686-4965 Please call 603-898-2181 with any questions.