Vital Statistics Form

Referred By:
Vital Statistics Form
This form must be typed or printed clearly.
Name of Deceased*
First Middle Last
Email*
Date of death:
Time
: HH
MM
SSN
Age
Date of birth:
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

CREMATION SOCIETY OF AMERICA
Serving Dade, Broward, Palm Beach Counties
Society Executive Office 6281 Taft St. Hollywood, Fl 33024
BROWARD * DADE AND PALM BEACH *
954-965-1636- Phone 954-987--2997- Fax
NAME OF DECEASED:
DATE OF BIRTH:
AGE:
LOCATION OF DECEASED:
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

Necessary Forms

Step 1 of 3

Vital Statistics Form

CLOTHING RELEASE

CREMATION SOCIETY OF AMERICA