N.Y.C. Funeral & Cremation Service Inc.

VITAL STATISTICS

All information provided by the family must be 100% correct for the death certificate. All fields are required.
(Do not use autofill on computer)

DECEASED INFORMATION

Name of Deceased (Decedent)

Deceased (Decedent) Legal Address (include apt. number, st, city, state, zipcode)

City

State

Zip

Date of Birth

Place of Birth (City, State or Country)

Date of Death

Place of Death (City)

State

Hospital or Nursing Home or Medical Examiner (medical examiner case number) where person Died

Social Security Number (if you do not know social security-enter all zeros)

Estimated weight (lbs.) of Decedent [Numbers Only, No Letters!]

Occupation [Job they did when working] (Do not enter "Retired")

Type of Industry

Highest Level of Education (8th grade or less, 9-12 no diploma, H.S, Some College no degree, BA, MA, Ph.D, Unknown)

Gender

Male Female

Veteran

Branch of Service

For NYC deaths, you must submit the original DD214 Honorable Discharge Paper in order to have veteran status on the death certificate.

Name of Spouse (Including Maiden Name)

Marital Status (Never Married, single, married, divorced, widow etc)

If legally married, spouse is next of kin and must sign.

Hispanic or non-Hispanic

Race as defined by US census White, Black or African American, other- Specify

Father's Name (First and Last Name)

Mother's Name (First and Last include Maiden Name)

Next of Kin

Relationship

Next of Kin Legal Address (include apt. number, st, city, state, zipcode)

City

State

Zip

Home#

Cell Phone

I agree that all above information is correct. I certify that I am the legal next of kin of the Decedent.

Name of Person Signing

Signature

Date Signed