Standard Death Certificate Information

Standard Death Certificate Information Please Print Clearly

Legal Name ___________________ ___________________ ______________________ First

Middle

Last

Social Security Number _____-___-_____ Ever in U.S. Military _____yes _____no Date of Birth ________________ City and State of Birth_________________________ Residential Address ________________________ _____________ ______________ City

Indiana

County ________________ Zip___________ Within City Limits _____ yes _____no Occupation_______________________ Industry____________________ Marital Status ____ Married _____Married, but separated _____Widowed ____ Divorced ____ Never Married Spouse’s Name _________________ _________________ _______________________ First

Middle

Last (maiden name if wife)

Father’s Name _________________ _________________ _______________________ First

Middle

Last

Mother’s Name ________________ __________________ _______________________ First

Middle

Last

Mother’s Maiden Name ____________________ Level of Education- check one th

___ 8 grade or less

Decedent’s Race –check one ___ White

___ 9th-12th grade; no diploma

___ Black or African American

___ High school graduate/GED

___ American Indian – Name Tribe ________________________

___ Some college credit; no degree

___ Asian Indian

___ Associate degree

___ Chinese

___ Bachelor’s degree

___ Filipino

___ Master’s degree

___ Japanese

___ Doctorate; PhD, EdD, MD

___ Vietnamese

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___ Other Asian – Specify________________________________

Of Hispanic Origin _____ Yes _____ No

___ Native Hawaiian

If yes please specify:

___ Guamanian or Chamorro

___ Mexican

___ Puerto Rican

___ Samoan

___ Cuba

___ Other

___ Other Pacific Islander – Specify________________________

Specify____________________________________

___ Other – Specify_____________________________________

Informant or Next of Kin Full Name ____________________ ___________________ __________ __________ First

Middle

Last

Relationship

Mailing Address _________________________ ___________ ____________ _______ Street Number or P.O. Box

City

State

Phone Number(s)______________ _________________ FOUNTAIN SQUARE CREMATION & FUNERAL SERVICES 1420 PROSPECT STREET, INDIANAPOLIS IN 46203 317-632-6576 WWW.FOUNTAINSQUAREFUNERAL.COM

Zip