Step 2Information for Death Certificate

1Vital Statistics Information

2Next of Kin Information

3Review Your Information... Then Submit Below

I AM PLANNING FOR:*
DECEASED LOCATION?*
As of this moment, where is the deceased?
What Hospital, Nursing Home or Hospice?*
Current location of deceased. Please provide the locations name, city and phone (If Known).
WHICH MEDICAL EXAMINER?*
Select the medical examiner's office where the deceased is located.
ADDRESS WHERE DECEASED IS LOCATED*
Street Address Address Line 2 City State ZIP Code
What Funeral Home?*
Please provide the name, address and phone number of the funeral home where the deceased is located.
FULL LEGAL NAME OF PERSON TO BE CREMATED:*
First Middle Last Suffix
MAIDEN NAME or BIRTH NAME OF PERSON TO BE CREMATED*
The surname/family name (last name) of the person being cremated that was given at birth and was listed on the birth certificate.
GENDER OF PERSON TO BE CREMATED:*
RACE OF PERSON TO BE CREMATED:*
ADDRESS OF PERSON TO BE CREMATED:*
Address of residence of person to be cremated. This could be the address of a nursing home or convalescence facility if that is where the person resides/resided.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
IS THE ABOVE ADDRESS IN THE CITY LIMITS?*
COUNTY OF RESIDENCE OF PERSON TO BE CREMATED:*
Example: Tarrant, Dallas, Denton, etc.
DATE OF BIRTH OF PERSON TO BE CREMATED:*
MM slash DD slash YYYY
PLACE OF BIRTH OF PERSON TO BE CREMATED:*
City State / Province / Region Country
SOCIAL SECURITY NUMBER (xxx-xx-xxxx) OF PERSON TO BE CREMATED:*
We are required to notify social security when a death has occurred. This is also required to complete a Texas Death Certificate.
NAME AS SHOWN ON SOCIAL SECURITY CARD:
Oftentimes, the name that a person goes by, or what is shown on a driver's license or birth certificate, isn't the same as what is on their Social Security card.
MARITAL STATUS OF PERSON TO BE CREMATED:*
PERSON TO BE CREMATED SPOUSE'S FULL NAME:*
First Middle Last Suffix
PERSON TO BE CREMATED SPOUSE'S MAIDEN NAME or BIRTH NAME:*
The surname/family name (last name) that was given at birth and was listed on the birth certificate.
PERSON TO BE CREMATED, FATHER'S FULL NAME:*
First Middle Last Suffix
PERSON TO BE CREMATED, MOTHER'S FULL NAME:*
First Middle Last Maiden
PERSON TO BE CREMATED'S HIGHEST LEVEL OF EDUCATION:*
USUAL OCCUPATION OF PERSON TO BE CREMATED:*
The job/type of work one primarily did within a particular industry. Example: Homemaker, Teacher, Nurse, Loan Officer, Electrician, etc.
KIND OF BUSINESS/INDUSTRY OF PERSON TO BE CREMATED:*
The type of industry one was involved in primarily throughout their life. Example: Domestic (Household), Education, Healthcare, Banking, Construction, etc.
WAS THE PERSON TO BE CREMATED IN THE MILITARY?*
WAS THE PERSON TO BE CREMATED EVER A PEACE OFFICER?*
Ever a peace officer in the State of Texas?

INFORMANT:*
Person providing information about the deceased
First Last
ARE YOU THE LEGAL NEXT OF KIN?*
A person's next of kin is that person's legal spouse or closest living blood relative.
INFORMANT'S RELATIONSHIP:*
Your relationship to the person you are planning for
INFORMANT'S ADDRESS:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
INFORMANT'S PHONE NUMBER:*
Enter the phone number where you can most easily be reached.
INFORMANT'S EMAIL:*
Enter your email and we will send you a copy of this form.
Enter Email Confirm Email
LEGAL NEXT OF KIN (if not the informant):*
Next of kin refers to the nearest blood relative of a person, including the surviving spouse. Example: Spouse, Adult Children, Parents, Adult Grandchildren, Siblings, Grandparents, Nephew/Niece, etc.
First Middle Last Suffix
NEXT OF KIN'S RELATIONSHIP:*
What is the next of kin's relationship to the deceased?
NEXT OF KIN'S ADDRESS:
Street Address City State ZIP Code
NEXT OF KIN'S PHONE NUMBER:*
The phone number where this person can most easily be reached.
HOW DID YOU HEAR ABOUT US?*
We would love to know how you heard about our services.
NAME OF HOSPICE OR HOSPITAL:*
The name of the hospice or hospital that referred you to us.
IF OTHER, PLEASE ELABORATE:*
Please be more specific on how you found out about our services.

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