HomeServicesProductsGetting StartedObituariesContact UsAdmin Certificate of Death Please enable JavaScript in your browser to complete this form.Full Name of Decedent *FirstMiddleLastSex *MaleFemaleDate & Time of Death *DateTimeMultiple Choice *ActualApproximatePresumedFound onDate of Birth *AgeIf Under 1 YearIf Under 1 DayWas Decedent Ever in U.S. Armed Forces *YesNoUnknownBirthplace (U.S. State or Foreign Country) *Social Security NumberIf No SSN, Check Appropriate Box *NoneNot ObtainableUnknownUsual Residence of Decedent *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty of Decedent's ResidenceInside City or Town Limits?YesNoPersonal Data of DecedentRace of Decedent (Check one or More)WhiteBlack or African AmericanFilipinoKoreanAsian IndianNative HawaiianChineseGuamanlan or ChamorroSamoanJapaneseVietnameseUnknownAmerican Indian or Alaskan NativeOther Pacific IslanderOther AsianOtherIf American Indian or Alaskan Native Please SpecifyIf Other Pacific Islander Please SpecifyIf Other Asian Please SpecifyIf Other Please SpecifyOf Hispanic Origin?YesNoIf Yes, Specify Cuban, Mexican, Puerto Rican, etc.Central or South AmericanCubanMexicanPuerto RicanUnknownOtherIf Other Please SpecifyEducation (Specify Only Highest Grade Completed) *Elementary / Secondary (0-12)High School DiplomaGEDSome CollegeAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate / Professional DegreeUnknownHow Many Years Completed? *1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years11 Years12 YearsCitizen of What CountryUsual or Last OccupationKind of Business or IndustryMarital Status *Never MarriedMarriedDivorcedWidowedSeparatedUnknownIf Married or Widowed, Name of Spouse (If Divorced Leave Blank)Name of Decedent's Father (First, Middle, Last, Suffix)Name of Decedent's Mother (First, Middle, Last, Suffix) (copy)Informant's DetailsInformant - Or Source of Information - RelationshipFull Name of Informant or Name of SourcePlace of DeathName of Hospital or Institution of Death (If None, So State)Select One (If Death Occurred in Hospital)DOAOut Patient Emergency RoomInpatientSpecify if Death Occurred Somewhere Other Than a HospitalHospice FacilityNursing HomeLong Term Care FacilityDecedent's HomeCorrectional FacilityOtherIf Other Please SpecifyLocation of DeathAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty of Death (If Independent City, Leave Blank)Only the Following May Legally File a Death CertificateLicensed Funeral Director / Licensee / Virginia State Anatomical Program / Next of KinMethod of DispositionBurialEntombment / MausoleumCremation / IncinerationBurial at SeaDonationRemoval From State (If Known, Check Final Method of Disposition When Removing from State, from Options Shown)OtherIf Other Please SpecifyPlace of Disposition - Name of Cemetery or CrematoryPlace of Disposition - Address of Cemetery or CrematoryAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDigital Signature of Funeral Director / Licensee, VSAP or Next of KinDirector / Licensee's No.Name of Funeral Home or FacilityAddress of Funeral Home, Facility, VSAP, or Next of KinAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSubmit