Vital Statistics | Whidden-McLean Funeral Home & Crematory

1. Decedent's Name (First, Middle, Last, Suffix)*

2. Date of Birth*

3. Sex

4a. Age - Last Birthday (Years)

4b. Under 1 Year - Months/Days

4c. Under 1 Day - Hours/Minutes

5. Date of Death

6. Social Security Number

7. Birthplace (City, State, or Foreign Country)

8. County of Death

9. Place of Death

10. Facility Name (If not institution, give Street Address)

11a. City, Town, or Location of Death

11b. Marital Status

12. Inside City Limits?

13. Surviving Spouse's Name (If wife, give Maiden Name)

14a. Residence - State

14b. County

14c. City, Town, or Location

14d. Street Address

14e. Apt. Number

14f. Zip Code

15a. Decedent's UsualOccupation

15b. Business/Industry

16. Decedent's Race (Specify)

17. Hispanic or Haitian Origin? (Specify)

18. Education (Highest Level Completed)

19. Servied in US Armed Forces?

20. Father's Name (Firsst, Middle, Last, Suffix)

21. Mother's Name (First, Middle, Maiden Surnmae)

22a. Informant's Name

22b. Relationship to Decedent

23a. New Informant's Mailing - State

23b. City or Town

23c. Street Address

23d. Zip Code

24. Place of Disposition (Cemetery, Crematory, etc.)

25a. Location - State

25b. Location - City or Town

26a. Method Disposition

Vital Statistics Form