Vital Statistics Form

Vital Statistics

Full Legal Name of Deceased:

Decedents First Name

Decedents Middle Name

Decedents Last Name

Decedents Maiden Name(if applicable)

Date of Birth

City of Birth

Date of Death

State/Country of Birth

Full Legal Name of Deceased's Mother

First Name

Middle Name

Last Name

Full Legal Name of Deceased's Father

First Name

Middle Name

Last Name

Social Security Number of Deceased

Marital Status

Full Legal Name of Spouse (if applicable)

First Name

Middle Name

Last Name

Occupation(DO NOT PUT RETIRED)

Industry

Did the decedent ever serve in the armed forces?

YesNo

If yes, what branch?

Do you have a copy of Military Honorable Discharge Papers?

YesNo

(If a Veteran)

Upload Honorable Discharge Papers (DD-214)(If a Veteran)

Was the decedent ever a police officer in Texas?

YesNo

Ethnicity

Highest Level of Education

Home Address of Deceased

Street

City

State/Province

ZIP/Postcode

Name of Informant

First Name

Middle Name

Last Name

Home Phone

Email Address

Cell Phone

Relationship to Decedent

Home Address of Informant

Street

City

State/Province

ZIP/Postcode

Number of Death Certificates Requested*

*Remember that there is no suggested number for death certificates. We recommend that you request a few extra copies in case something comes up.

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7746 Belbay St.
| Houston, TX 77033
| Tel: 1-281-742-0591
|

Respect of Life Funeral Home
| 7746 Belbay St.
| Houston, TX 77033
| Tel: 1-281-742-0591
|

Respect of Life Funeral Home
| 7746 Belbay St.
| Houston, TX 77033
| Tel: 1-281-742-0591
| Fax: 1-832-834-4976

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