Worksheet For Funeral Director

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CASE ID NUMBER
New Jersey Department of Health
ELECTRONIC DEATH REGISTRATION SYSTEM
WORKSHEET FOR FUNERAL DIRECTOR
CREATE CASE INFORMATION
Check (X) if Received for Limb Only:
1a. Legal Name of Decedent
First Name
Middle Name
Last Name
Suffix
2. Sex
Male
Female
Unknown
Place of Death:
35c. County
35b. Municipality
31. Date of Death (Month/Day/Year)
DECEDENT INFORMATION
1b. Also Known As (AKA), If Any (Enter up to 3 aliases.)
ALIAS 1
First Name
Middle Name
Last Name
Suffix
ALIAS 2
ALIAS 3
4a. Age-Last Birthday (Years)
3. Social Security Number
5. Date of Birth (Month/Day/Year)
4b. Under 1 Year (Months/Days)
4c. (Under 1 Day (Hours/Minutes)
6. Birthplace (City and State/Foreign Country)
Foreign Country
State
City
RESIDENCE INFORMATION
Country
7a. State
7b. County
7c. Municipality/City
7g. Inside City Limits?
Yes
No
Unknown
7d. Street Address
7e. Apt. No.
7f. Zip
ARMED FORCES INFORMATION
8a. Ever in US Armed Forces?
Died on Active Duty?
Yes
No
Unknown
Yes
No
Unknown
8b. If Ever in US Armed Forces, Name of War
8c. War Service Dates
From:
To:
REG-51
NOV 16
Page 1 of 3 Pages.

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