Basic Vital Statistic Information Form

If you would prefer to print this form to fill out by hand and mail in, please select this option.

First Name

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Middle Name

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Last Name

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Suffix

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Your Email (Person Filling Out This Form)(*)

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Doctor

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Doctor's Phone

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Date of Birth

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Place of Birth

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Funeral Home Use

DOD

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TOD

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POD

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Member of the U.S. Armed Forces?

Yes

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Branch

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Rank

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War

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Service Number

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Date Entered

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Date Seperated

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Marital Status

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Most Recent Spouse Name

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Highest level of education?

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Ancestry

Non-Hispanic

Hispanic

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If Hispanic, Nationality

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Usual Occupation, even if you are retired?

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Employer

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Residence

State

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County

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City or Town

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Street and Number

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Zip

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Phone

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Cell Phone

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Parents

First Name

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Father's Middle Name

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Father's Last Name

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Suffix

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Mother's First Name

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Mother's Middle Name

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Mother's Last Name

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Contact

Name

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Relationship

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State

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County

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City or Town

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Street and Number

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Zip

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Contact's Phone

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Method of Disposition

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Place of Final Disposition

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Number of Certified Copies of the Death Certificate

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Obituary Requested

Yes

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Which Papers

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I/we have proofread this information and I confirm that all the information listed above is correct to the best of my knowledge. Any corrections that need to be made after filing will result in a $25 correction fee and a 4-6 week delay on corrected copies and State of Maine corrected copy fee’s (if applicable).

******I/we also understand that payment is due upon completion of services and that payment is due at the time of the picking up of the remains in the case of direct cremation.

Signature

Sign Above

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Date

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Please verify you are human(*)

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