Vital Information Form | Sacred Space Memorial | San Jose, Walnut Creek, Santa Clara, funeral home and cremation

Name of Decedent (First)

Middle

Last

AKA, Also known as ~ Include full AKA (First, Middle, Last)

Date of Birth

Age

Sex

MaleFemale

Birth State / Foreign Country

Social Security Number

Ever in U.S. Armed Forces?

YesNoUnknown

Education - Highest Level / Degree

Was Decedent Spanish/Hispanic/Latino

YesNo

If yes:

Race

Occupation - Type of Work most of Life. DO NOT USE RETIRED

Kind of Business (e.g. grocery store, education, etc)

Years in Occupation

Decedent's Home Address (Street and Number)

Street

City

State/Province

ZIP/Postcode

Years in County

State / Foreign Country

Informant's Name

Relationship

Informant's Phone Number With Area Code

Informant's Address

Street

City

State/Province

ZIP/Postcode

Informant's Mailing Address

Street

City

State/Province

ZIP/Postcode

Informant's Phone Number (with Area Code)

Name of Spouse (if living)

Middle

Last (If wife, enter Maiden Name)

Name of Decedent's Father - First

Middle

Last

State

Name of Decedent's Mother - First

Middle

Last (Maiden Name)

State

Final Disposition (Choose One)

BurialCremation

If cremation - Final Disposition of Cremated Remains (Choose One)

ResidenceSea Scatter

Place of Final DispositionFull Name, Address and Zip of person(s) who will keep cremains at their residence, or cemetery name, address and zip or location where cremains are to be scattered

Physician's Name

Physician's Phone

Physician's Fax

Number of Certified Copies (of Death Certificate)

Physician's Address

Street

City

State/Province

ZIP/Postcode

How did you hear about us?

Date Submitted

I have read the above information, and state that it is true and correct, and release Sacred Space Memorial FDR 3424 from any charges that may occur in the correction of the original certificate due to this information

FD 2237 | CEB1288

FD 2237 | CEB1288

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