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- Death Certificate Form

Vital Record and Obituary

This information will be used to complete the official death certificate form. This worksheet is not to be forwarded to the Office of Vital Statistics.

DECEDENT'S LEGAL NAME
(First, Middle, Last, Suffix
SEX
- Male
- Female
IF FEMALE, NAME PRIOR TO FIRST MARRIAGE
DATE OF DEATH
MM
DD
YYYY
SOCIAL SECURITY NUMBER
DATE OF BIRTH
MM
DD
YYYY
AGE AS OF LAST BIRTHDAY
(years)
AGE IF LESS THAN 1 YEAR OLD
If under 1 year, please give Months/Days.
If under 1 day, please give Hours/Minutes.
PLACE OF BIRTH
(City and State or Foreign Country)
WAS DECEDENT EVER IN U.S. ARMED FORCES?
- Yes
- No
- Unknown
PLACE OF DEATH
- Hospital - Inpatient
- Hospital - ER/Outpatient
- Hospital - DOA
- Nursing Home
- Hospice Facility
- Assisted Living Facility
- Decedent's Residence
- Other
Other (Specify)
Place of death
FACILITY NAME
(If not institution, give street and number)
COUNTY OF DEATH
CITY OR TOWN OF DEATH
ZIP CODE
MARITAL STATUS
- Married
- Married, but separated
- Widowed
- Divorced
- Never Married
- Unknown
SURVIVING SPOUSE
(If wife, give name before first marriage)
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code
INSIDE CITY LIMITS?
- Yes
- No
- Unknown
FATHER'S NAME
(First, Middle, Last)
MOTHER'S NAME PRIOR TO FIRST MARRIAGE
(First, Middle, Last)
INFORMANT'S NAME
(First, Middle, Last)
INFORMANT'S EMAIL
INFORMANT'S MAILING ADDRESS
Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code
RELATIONSHIP TO DECEDENT
METHOD OF DISPOSITION
- Burial
- Cremation
- Removal from State
- Donation
- Entombment
- Other
Other (Please Specify)
PLACE OF DISPOSITION
(Name of cemetery, crematory, or other place)
LOCATION
City or Town and State
ANCESTRY
What is this person's ancestry or ethnic origin? Italian, German, Dominican, Vietnamese, Hmong, French Canadian, etc. (Please Specify)
HISPANIC ORIGIN
- No, not Spanish/Hispanic/Latino
- Yes, Mexican, Mexican American, Chicano
- Yes, Puerto Rican
- Yes, Cuban
- Yes, Central American
- Yes, South American
- Yes, other Spanish/Hispanic/Latino
- Unknown
(Check the box or boxes that best describe whether the decedent is Spanish/Hispanic/Latino. Check the "no" box if the decedent is not Spanish/Hispanic/Latino)
Other Spanish/Hispanic/Latino
Please specify
RACE
- White
- Black or African American
- American Indian or Alaska Native
- Asian Indian
- Chinese
- Filipino
- Japanese
- Korean
- Vietnamese
- Other Asian
- Native Hawaiian
- Guamanian or Chamorro
- Samoan
- Other Pacific Islander
- Other
- Unknown
(Check one or more boxes to indicate what race(s) the decedent considered himself or herself to be.)
American Indian or Alaskan Native (Please Specify)
(Name of the enrolled or principal tribes)
Other Asian (Specify)
Other Pacific Islander (Specify)
Other (Specify)
EDUCATION
- 8th grade or less
- 9th - 12th grade; no diploma
- High school graduate or GED
- Some College credit, but no degree
- Associate degree (e.g., AA, AS)
- Bachelor's degree (e.g., BA, AB, BS)
- Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA)
- Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
- Unknown
(Check the box(es) that best describes the highest degree or level of school completed at the time of death)
DECEDENT'S USUAL OCCUPATION
Give kind of work done during most working life. Do not use retired.
KIND OF BUSINESS/INDUSTRY
(Do not give name of company)
ADDITIONAL OBITUARY INFORMATION

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Resources

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Associations

National Funeral Directors Association
Kansas Funeral Directors Association
Cremation Association of North America

Affiliations

United States Department of Veterans Affairs
Leavenworth National Cemetery
Lawrence KS Chamber of Commerce

Contact Us

601 Indiana Street
Lawrence KS 66044

Phone: 785-843-5111

Toll Free: (800) 369-8858

Fax: (785) 842-0116

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