McCOMB & WAGNER Death Certificate Info

McCOMB & WAGNER

Death Certificate Vital Information Form

Required Information needed to complete the Death Certificate and other necessary documents

DECEDENT INFORMATION

First Name*:

Middle Name:

Last Name*:

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

McCOMB & WAGNER Death Certificate Info

VITAL INFORMATION