DEATH CERTIFICATE FAMILY OWNED AND OPERATED SINCE 1954 title titleMRSMISSMSOR Name Email Address 1a. Last 1b. First 1c. Middle Name of Decedent 2a. Date of Death 2b. Hour of Death 3. Gender 3. GenderMaleFemale 4. Race 4. RaceBlackWhiteHispanicAsianOther 5. Marital Status 5. Marital StatusMarriedNever MarriedWidowedDivorced 6. Surviving Spouse (if Wife, give Maiden Name) 7. Date of Birth 8a. Age Years 8b. Age Under 1 year (Months - Days) 8c. Age Under 1 Day (Hours - Minutes) 9.Birthplace (City and State or Foreign Country) 10. Usual Occupation (kind of work done most) 11. Kind of Business or Industry 12. Of Hispanic Origin? 12. Of Hispanic Origin? Yes No 13. Ever in U.S. Armed Forces? 13. Ever in U.S. Armed Forces? Yes No 14. Social Security Number 15. Decedent's Education (Highest completed) 16a. Place of Death 16a. Place of Death Hospital Inpatient Hospital ER/Outpatient Hospital DOA Non-Hospital Nursing Home Residence Other 16b. Name of Facility (if not in Facility, give street address or location) 16c. Place of Death in City Limits? 16c. Place of Death in City Limits? Yes No 17a. City, Town or Location of Death 17b. Parish of Death 18a. Residence Street Address (if rural specify rural route number or location) 18b. Parish of Residence 18c. State of Residence 18d. Usual Residence of Decedent (City, Town or Location) 18e. Zip Code 18f. Residence Inside City Limits? 18f. Residence Inside City Limits? Yes No 19a. Father's Last Name First Middle 19b. Father's Place of Birth 19c State 20a. Mother's Last Name First Middle 20b. Mother's Place of Birth 20c. State 21a. Name of Informant 21b. Informant's Address 21c. Date (Month, Day, Year) 22a. Method of Disposition 22a. Method of Disposition Burial Cremation Removal Other 22b. Date Thereof 22c. Name and Location of Cemetery or Crematorium 23a. Signature and Address of Funeral Director 23b. Facility Number 23c. License Number 24. Alterations 1 + 9 = Submit
