Death Certificate Worksheet

Use this worksheet to gather information that may be helpful during your arrangement conference.

Select Save PDF and email to download your completed PDF and an email draft addressed to kb@kerrbrothers.com with the PDF attached. Open the downloaded .eml draft in a compatible desktop email app, then select Send. If you use webmail or your email app cannot open the draft, attach the downloaded PDF to your email.

Family contact

Person completing this worksheet Relationship to the deceased Best phone number Email address

Death Certificate Information

Please provide the information exactly as it should appear on the death certificate. Your funeral director will confirm all entries.

Decedent's legal name - first, middle, and last (include any aliases or AKA names) Last name prior to first marriage, if applicable Sex Actual or presumed date of death Social Security number

Age and birth information

Age at last birthday (years) If under 1 year - months If under 1 year - days Date of birth If under 1 day - hours If under 1 day - minutes County of death Birthplace - city and state, or foreign country

Place of death

Choose one

Hospital - inpatient Hospital - ER or outpatient Dead on arrival Hospice facility Nursing home or long-term care facility Residence Other

If other, specify

Facility name, or street and number if not an institution City or town, state, and ZIP code

Marriage and employment

Marital status

Surviving spouse's full name (include name prior to first marriage, if applicable) Usual occupation - kind of work done during most of working life (do not enter “retired”) Kind of business or industry

Was the decedent ever in the U.S. Armed Forces?

YesNo

Usual residence

State County City or town Street and number ZIP code

Inside city limits?

YesNo

Education, Hispanic origin, and race

Highest degree or level of school completed

Hispanic origin

No, not Spanish/Hispanic/Latino Mexican, Mexican American, or Chicano Puerto Rican Cuban Other Spanish/Hispanic/Latino

If other, specify

Parents

Father's name - first, middle, and last Mother's name prior to first marriage - first, middle, and last

Disposition

Method of disposition - choose one If other, specify

Place of disposition - cemetery, crematory, or other place Location - city, town, and state

Informant information

Prefix First name Middle name Last name Signature of informant (type full legal name) Street number Street Apartment City State ZIP code Phone number Relationship to deceased Email address Number of certified copies Send certified copies to (Pickup from the funeral home is preferable, but we will mail them if requested.)

Sender verification and electronic signature

Please proofread every entry before signing. Your signature and confirmation will be included in the completed worksheet.

Sender's electronic signature (type your full legal name) — required Date and time signed

Sender's proofreading confirmation — required

I confirm that I have reviewed and proofread all information in this Death Certificate Worksheet and that it is correct to the best of my knowledge. I intend my typed name to serve as my electronic signature.

Kerr Brothers Funeral Home • Family Resource Center • Please confirm all information with your funeral director.