Below is the statistic information needed to fill out and complete the death certificate of your loved one. Please accurately fill out all the information below as this will be used when filling out the death certificate. If you are unsure, leave blank until the correct information is verified.

Full Legal Name of Deceased

Place of Death Time of Death

Primary Care Doctor

Date of Birth Date of Death Age

Social Security Number

Home Address

Birthplace (city & state)

Marital Status: Never Married Married Divorced Widowed

Husband's Name Wife's Maiden Name

Occupation Industry

Highest Grade Level Completed

Father's Name Mother's Maiden Name

Race/Nationality

Veteran Branch Flag DD214

Number of Death Certificates Requested

Family Member Receiving Death Certificates

Informant

Relationship

Address

Telephone Number

Email Address

By signing below, you give us permission to use the above information in the completion of the death certificate of your loved one. You also agree that if there are any errors due to incorrect information provided above and the certified death certificate needs to be amended, you are responsible for the necessary fees for the amendment and the replacement certified copies.

Signature Certificate

Document name: Death Certificate Information

Unique Document ID: 4126e649c742983b94bde5bab6e791dcbc8e7b0c

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Timestamp	Audit
April 26, 2021 8:47 am CST	Death Certificate Information Uploaded by Kremer Funeral Home - [email protected] IP 209.34.204.214

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https://kremerfuneralhome.com/

Audit Trail Serial# 4682bfc38019db26deaf1069374f192f