Vital Statistics Form
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2Vital Statistics Form
(Do not abbreviate. Check spelling if you are not certain. Be careful, errors or
omissions may delay processing of death certificates.)
Full Name (First, Middle, Last):
__________________________________________
Maiden Name (First, Middle, Last): __________________________________________
Address (street and number):
__________________________________________
City, State, Zip Code: ____________________________________________________
Town and County:
_____________________________________________________
Social Security Number: ___________________________________________________
Birthplace (State or if not from U.S then name Country): _________________________
Citizen of What Country?
________________________________________________
Race (White, Black, Native American etc): ____________________________________
Date of Birth: ____________________________________________________________
Marital Status (Single, Divorced, Married or Widow(er)) : ________________________
Name of Spouse:
______________________________________________________
Occupation (for most of working life): ________________________________________
Industry (kind of business i.e. Insurance, farming etc.): ___________________________
Name of Father: _________________________________________________________
Father’s Place of Birth: ____________________________________________________
Father’s Date of Birth (or year): _____________________________________________
Name of Mother: _________________________________________________________
Mother’s Place of Birth: ____________________________________________________
Mother’s Date of Birth (or year): ____________________________________________
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Parent category: Legal