Statistical Information Form

Families frequently ask, "What are the steps for getting a death certificate?"

Steps to ordering initial certified death certificate(s):

The top part of the death certificate is completed by the funeral director from information provided by family.
The cause and manner of death is completed by the medical provider (PCP) or medical examiner.
The county (in which the death occurred) records the death certificate and certified copies may be ordered for the Informant.

Many families have found this secure Statistical Information Form (see fillable fields below) useful while gathering the information for the top part of the death certificate. You may skip fields and work directly with your funeral director if you prefer.

Statistical Information Form

Atneed Vital Statistics Form

Full Name (First, Middle, Last, Suffix) (Do not abbreviate)

Date of Death

Sex

Current Age

Social Security Number

County of Death

Date of Birth

Birthplace

Education

Hispanic

Race

U.S. Armed Forces

If Yes, Which Branch?

Combat

If Yes, Please Specify

Spouse's Social Security Number

Spouse's Date of Birth

Residence Street Address

City

State

Zip Code

County

Inside City Limits

Marital Status at Time of Death

Spouse’s Full Maiden Name

Usual Occupation

Kind of Business or Industry

Father’s Full Name

Mother’s Full Maiden Name

Informant's Name

Relationship

Preferred Phone Number

Alternate Phone Number

Informant’s Mailing Address

Method of Disposition

Statistical Information Form

Families frequently ask, "What are the steps for getting a death certificate?"

Statistical Information Form

Atneed Vital Statistics Form

A Year of Grief Support