Vital Statistics Form

Vital Statistics Form
Referred By:
Name of Deceased*
First Middle Last
Email*
Date of death:
Date Format: MM slash DD slash YYYY
Time

: HH

MM
SSN
Age
Date of birth:
Date Format: MM slash DD slash YYYY
Sex:
Armed Forces:
- Yes
- No
Birthplace
City State / Province / Region Country
Place of Death
- Hospital
- Residence
- Hospice
- Nursing Home
- Assisted Living Facility
City:
Inside City Limits:
- Yes
- No
County of Death:
Occupation: (Do not use Retired)
Business:
(Type of business, eg. factory, manufacturer)
Marital Status:
Spouse:
(if wife, give maiden name)
Residence
Street Address Address Line 2 City State ZIP Code
Inside City Limits:
- Yes
- No
Decedent of Hispanic Or Haitian Origin?
- No - Not of Hispanic/Haitian Origin
- Unknown if Hispanic/Haitian Origin
- Yes, of Hispanic/Haitian Origin (Select One Below)
If Yes, Of Hispanic/Haitian Origin (Select One)
- Haitian
- Mexican
- Puerto Rican
- Cuban
- Other Hispanic (Specify Below)
Other Hispanic
Race:
(Do not use hispanic)
Education:
(8th Grade or Less) (High School) (Degree AS, BS, MA, PHD)
Father's Name:
First Middle Last
Mother's Name:
First Middle Last
Informant's Name:
Informant's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:
Relationship:
Doctor's Name:
Doctor's Phone:
This form is used to complete the death certificate, which is a legal document and filed with the
State of Florida. It is therefore important to fill completely and accurately with the proper spelling
of names and places. Corrections to the death certificates require 6 to 8 weeks and there are fees
that apply.

I certify that to the best of my knowledge that all information is true and correct.
Signature of person completing form

CLOTHING RELEASE
NAME OF DECEASED:
The undersigned legally authorized to interact with Cremation Society of America
for the above named decedent, hereby request that the following items to be
properly disposed of by cremation by Fred Hunter Crematory.

Any clothing items including but not limited to sheets, pillows and/or blankets.

I understand that these items may be soiled and the Cremation Society of America
has recommended proper disposal.
SIGNED :X
Legally Authorized Next of Kin:
Date
Date Format: MM slash DD slash YYYY

RELEASE FORM
NAME OF DECEASED:
DATE OF BIRTH:
Date Format: MM slash DD slash YYYY
AGE:
LOCATION OF DECEASED
Please put full address of location below.
ADDRESS OF LOCATION DECEASED:
Street Address Address Line 2 City State ZIP Code
I undersigned hereby authorizes the release of the above named decedent to
CREMATION SOCIETY OF AMERICA to care and prepare for disposition. I hereby
represent that I am the nearest degree of relationship to the deceased.
Signed
Legally Authorized Next of Kin
Relationship to Deceased
Witness Signature:
Print Name
CREMATION SOCIETY OF AMERICA

Cremation Forms – Immediate Need

Cremation Forms - Immediate Need

Step 1 of 3

CLOTHING RELEASE

RELEASE FORM

CREMATION SOCIETY OF AMERICA