Vital Statistical Information For Texas Death Certificate printable pdf download

VITAL STATISTICAL INFORMATION FOR TEXAS DEATH CERTIFICATE

PLEASE PRINT LEGIBLY

LEGAL NAMES NO NICKNAMES

Date of Death: ____________________________________ Social Security Number: __________________________

First Name: ________________________________________Middle Name: _________________________________

Last Name: _________________________________ Suffix: ________ Maiden Name: _________________________

Date of Birth: ___________________________________ Age: ______________ Gender: Male _____Female _____

Birthplace: City ___________________________________ State/ Country _________________________________

Marital Status:

_______ Widowed _______ Divorced _______ Never Married _______ Married

Surviving Spouse: First _________________Middle _____________Last ______________ Maiden ______________

Deceased Address: ___________________________________________ City: ________________________________

State: ____________________ Zip: ___________ County: ________________Inside City Limits:_____ Yes _____No

Father’s Name: First _____________________Middle ______________________ Last _________________________

Mother’s Name: First ____________________ Middle _____________________ Maiden______________________

Education: _____8

grade or less _______ 9

– 12

no diploma ________ High School Graduate or GED

____Some College no degree ____ Associate ____ Bachelor’s_____ Master’s ______

Doctorate _____ Trade

Usual Occupation: ___________________________

Type of Industry: ___________________________________

Ever a Police Officer in Texas: _______ Yes _______ No

Ever in the Armed Forces: ________ Yes _______ No Which Branch: ____________________________________

Hispanic: ________Yes _________ No Race: _________________________________________________________

Informants Relationship to Deceased: ______________________________________

Informants Name: First ____________________________________ Last ___________________________________

Informants Address: ______________________________________ City: ___________________________________

State: _________________________________ Zip: ________________ Phone: _______________________________

Email Address for contract review: ___________________________________________________________________

Place of Death: ___________________________________________________________________________________

City : _____________________________________________ Zip: _________________ County: _________________

*Certified copies of the Death Certificates are $21 for the 1

copy and $4 for each additional copy.

How many, if any, certified copies of the death certificate will you need? ________________________________

Please FAX ALL COMPLETED FORMS TO 877-800-1150

Vital Statistical Information For Texas Death Certificate