Biographical Information

This form collects information needed for a death certificate (front page) and an obituary (back page). Please PRINT clearly and fill in all the information available to you. Please bring this information with you to the arrangement conference, and your funeral director will review it with you.

Name of Deceased:

Legal Residence:

Father’s Name:

Mother’s Name:

Spouse’s Name:

Cannot use “retired,” if retired, use previous occupation. Examples: Machine Operator / Manufacturing; Homemaker / Own Home

Informant (Next of Kin) Contact Information:

Family Names for Obituary *Please indicate deceased family members with (dec) next to name*

If you would like to include grandchildren’s names in obituary, please print names on a separate list