First Name:

Middle Name:

Social Security Number:

Age:

Date of Birth:

Place of Birth (City & State):

Date of Death:

Place of Death:

Town of Death:

Was Decedent ever in the US Armed Forces (yes or no):

Decedents Usual Occupation (done during most of working life) :

Kind of Business/Industry:

Decedents Education (Elementary 1-12, or college 1-4, or 5+):

Marital Status

Most Recent Spouse (if wife, give maiden name & living or deceased)

Ancestry (French, English, Irish, etc.):

Race (White, Black, American, Indian, etc.):

Residence (City or Town):

Residence (Street and Number):

Father’s Last Name (and Jr., Sr. etc.):

Father’s First Name:

Father’s Middle Name:

Mother’s Maiden Surname:

Mother’s First Name:

Mother’s Middle Name:

Informant (the person the State can contact regarding the above information):

Name:

Address:

Telephone Number:

Email: