Vital Statistics Form - Fisher Funeral Home & Cremation Services

Deceased Vital Statistics for Death Certificate

Please fill out this section about the deceased. Put “Unknown” for any fields you do not know.

Please check which one applies*
Pre-Need (Death has not taken place)At Need (Death has taken place)

First Name*

Middle Name*

Last Name*

Date of Birth

Sex

Date of Death (For Pre-Death put N/A)

Name at birth or other name used for personal business (include AKA's if any)

Birth Place

Birth City

Birth State

Location of Death

Location

Address of Location

Method of Disposition
BurialCremationEntombmentDonation

Current Residence

Please fill out this section about the deceased.

Deceased's Street Address*

City*

State*

Zip*

Personal Information

Race

Ancestry

Hispanic Origin:
YesNo

Social Security Number

Highest Education*

U.S Military Veteran:
YesNo

Do You Have a Copy of the Discharge Papers?
YesNo

Please indicate job title(s)

Please indicate what industry they worked in

Marital Status*

Name of Surviving Spouse

Name of the Decedent's Father

Decedent's Mother Name AT Birth

Contact Person

Please fill out this section about the person signing the form.

Your First Name*

Your Last Name*

Your Phone Number*

Your Email*

Your Relationship to the Deceased*

Your Home Address
Street Address*

City*

State*

Zip*

Please select an option

Please take a moment to review your responses before clicking "Next". Once you do, a PDF document will be generated that requires your electronic signature to finalize the process. Please note that we will not receive a copy of the form until it has been fully signed. Once you have completed the signature process, please contact us directly to complete your request.