DEATH CERTIFICATE INFORMATION FORM

IMPORTANT NOTE: Information you provide here in this form will be placed on the Death Certificate. We do not typically contact the family to check and verify if the information provided is correct. We expect that your input is submitted accurately as you intend it. If changes or corrections are requested after the Death Certificate has printed and the corrections required are due to family error, then an additional administrative fee of $75 will be incurred to reorder and reobtain new corrected Death Certificates- Plus the cost of the corrected Death Certificates. If you do not know the answer to a particular imput please put UNKNOWN.

DECEDENT INFORMATION

Select to Acknowledge Important Note:*:

First Name of Decedent*:

Middle Name of Decedent:

Last Name of Decedent*:

Social Security Number*:

Birthdate (MM/DD/YYYY)*:

Date of Death (If known)*:

Place of Death (If known)*:

Age*:

Gender*:

Male

Female

Decedent Address*:

Residence County*:

Is Residence in City Limits?*:

Yes

Unknown

Estimated Length of Time at Residence*:

Birthplace (City, State, Country)*:

Citizenship*:

Race*:

If Hispanic, Specify*:

Education (Highest Grade Completed)*:

Occupation (Most of Working Life/Not "Retired")*:

Industry of Occupation*:

Decedent's Marital Status*:

Surviving Spouse's Current Full Name*:

Surviving Spouse's (Maiden Name)*:

Decedent's Father's Full Name*:

Decedent's Mother's Full Name*:

Decedent's Mother's Maiden Name*:

Veteran- Yes/No?*:

Military Branch:

CONTACT PERSON / INFORMANT

Relationship to Decedent*:

First Name*:

Middle Name:

Last Name*:

Social Security Number*:

Telephone*:

Address*:

Email*:

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SERVICE AREA

_____________________

King - Pierce - Kitsap

Thurston - Mason

Lewis - Grays Harbor

Jefferson - Pacific