Death Certificate Outline
Blackburn & Sons Vernal Mortuary
Death Certificate Outline
Full Name of Deceased____________________________________________________________ Male___ Female____Date of Death__________________________________________________ City of Death_______________________________ County of Death________________________ Place of Death___________________________________________________________________ Social Security #_________________________________________________________________ Date of Birth________________________________Birth City_____________________________ Birth State_______________________________Birth County_____________________________ Marriage Status
_____Never Married
____Married
_____Widowed
___Divorced
Surviving Husband or Wife (maiden)_________________________________________________ Marriage Date_____________________________Place_________________________________ Residence_____________________________________________________________________ City_______________________________________State_______________________________ County___________________________________Zip___________________________________ Fathers Name___________________________________________________________________ Mothers Maiden Name____________________________________________________________ Physician or Medical Examiner______________________________________________________ Race___________________________________Education_______________________________ Usucal Occupation (Not Retired)____________________________________________________ Industry__________________________________________________ Military___________________Branch__________________________
INFORMANT_________________________________________________________________ Phone #____________________________________Cell #_______________________________ Address________________________________________________________________________ Email Address___________________________________Relationship______________________ 15 East 100 North, Vernal, Utah 84078,
435-789-2611
email: [email protected]
Death Certificate Outline
Full Name of Deceased____________________________________________________________ Male___ Female____Date of Death__________________________________________________ City of Death_______________________________ County of Death________________________ Place of Death___________________________________________________________________ Social Security #_________________________________________________________________ Date of Birth________________________________Birth City_____________________________ Birth State_______________________________Birth County_____________________________ Marriage Status
_____Never Married
____Married
_____Widowed
___Divorced
Surviving Husband or Wife (maiden)_________________________________________________ Marriage Date_____________________________Place_________________________________ Residence_____________________________________________________________________ City_______________________________________State_______________________________ County___________________________________Zip___________________________________ Fathers Name___________________________________________________________________ Mothers Maiden Name____________________________________________________________ Physician or Medical Examiner______________________________________________________ Race___________________________________Education_______________________________ Usucal Occupation (Not Retired)____________________________________________________ Industry__________________________________________________ Military___________________Branch__________________________
INFORMANT_________________________________________________________________ Phone #____________________________________Cell #_______________________________ Address________________________________________________________________________ Email Address___________________________________Relationship______________________ 15 East 100 North, Vernal, Utah 84078,
435-789-2611
email: [email protected]
