Certificate of Death – Affordable Cremations

Full Name of Decedent *

First

Middle

Last

Sex *

Male
Female

Date & Time of Death *

Date

Time

Multiple Choice *

Actual
Approximate
Presumed
Found on

Date of Birth *

Age

If Under 1 Year

If Under 1 Day

Was Decedent Ever in U.S. Armed Forces *

Yes
No
Unknown

Birthplace *

Address Line 1

City

State / Province / Region

Country

Social Security Number

If No SSN, Check Appropriate Box *

None
Not Obtainable
Unknown

Usual Residence of Decedent *

Address Line 1

City

State / Province / Region

Postal Code

Country

County of Decedent's Residence

Inside City or Town Limits?

Yes
No

Personal Data of Decedent

Race of Decedent (Check one or More)

If American Indian or Alaskan Native Please Specify

If Other Pacific Islander Please Specify

If Other Asian Please Specify

If Other Please Specify

Of Hispanic Origin?

Yes
No

If Yes, Specify Cuban, Mexican, Puerto Rican, etc.

If Other Please Specify

Education (Specify Only Highest Grade Completed) *

How Many Years Completed? *

Citizen of What Country

Usual or Last Occupation

Kind of Business or Industry

Marital Status *

If 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, Maiden)

Informant's Details

Informant - Or Source of Information - Relationship

Full Name of Informant or Name of Source

Place of Death

Name of Hospital or Institution of Death (If None, So State)

Select One (If Death Occurred in Hospital)

DOA
Out Patient Emergency Room
Inpatient

Specify if Death Occurred Somewhere Other Than a Hospital

If Other Please Specify

Location of Death

Address Line 1

City

State

Zip Code

County of Death (If Independent City, Leave Blank)

Only the Following May Legally File a Death Certificate

Licensed Funeral Director / Licensee / Virginia State Anatomical Program / Next of Kin

Method of Disposition

If Other Please Specify

Place of Disposition - Name of Cemetery or Crematory

Place of Disposition - Address of Cemetery or Crematory

Address Line 1

City

State

Zip Code

Digital Signature of Funeral Director / Licensee, VSAP or Next of Kin

Director / Licensee's No.

Name of Funeral Home or Facility

Address of Funeral Home, Facility, VSAP, or Next of Kin

Address Line 1

Address Line 2

City

State

Zip Code