Death Certificate Information Worksheet
Vital Statistics WorksheetPlease complete and Fax to (937) 675-2513
(ALL MUST BE ANSWERED) PLEASE PRINT
Decedents Legal Name: ________________________________
Sex: Male_____ Female:_____
Date of Death:________________
Social Security number:____________________________
Date of Birth:_____________________Birthplace:________________________
Ancestry: __________
Residence:
State:___________________County:____________________________
City or Town:_____________
Street and Number:_________________Apt. No.:__________________________
Zip Code:________
Inside City Limits?: Yes or No
Ever in Armed Forces?: Yes or No Branch:_________________
Date of Entry:_____________________Type of Separation:________________
Date of Separation:_____
Marital Status: Divorced___ Married___ Married, but separated___
Never Married___Widowed____
Surviving Spouse's Name:_________________________________
If wife, maiden name:______________
Decedents education:_______________(8th grade or less, HS graduate, college graduate and degree)
Was Decedent of Hispanic Origin? Yes or No
Describe origin:____________________________
Decedent's Race:___________________
Decedents Usual Occupation: __________________________________________________________
Kind of Business/Industry?: ___________________________________
Father's Name:___________________________________________________________________
Mother's Name,(prior to marriage):___________________________________________________
Informant's name:_________________________________________________________________
Relationship to Decedent:__________________________
Informant's Mailing Address: (Street and Number, City, State, Zip Code:
_____________________________________________________________________
Place of death: (check one)
Decedent's home____ Hospital-dead on arrival____ Hospital-ER/outpatient____
Hospital-Inpatient____ Hospice____ Nursing home/long term care___
Other________
Location/Address__________________________________________________
_______________________________________________________________
Facility Name (If not institution,street and number):___________________________
_____________________________________________________________________
City or Town, State and Zip Code: ___________________________________
County of death:___________________
Method of Disposition: Burial___ Cremation___ Donation___ Entombment___
Removal from state___Date of Disposition:_______________
Place of Disposition (Name of Cemetery, Crematory, or other place):_________________________________________________________________
Location (City/Town and County and State):
___________________________________
Cemetery Section, Lot Grave Number:____________________________
Name/Address/Telephone of Certifier (Physician or Coroner)
:_________________________________________________________________________
Military Time of Death_______
Was Case referred to Coroner? Yes or No
Name/Address/Telephone/Facsimile of Funeral Facility:
______________________________________________________________________
______________________________________________________________________
Number of certified copies:____________
Mail certified copies to funeral home or informant?_________________________
Please complete the information and forward to:Storer Mortuary Transport for completion of death certificate.FAX: (937) 675-2513
Death Certificate Information
Storer Mortuary Transport will prepare and file death certificates on our client's cases if they desire. In the State of Ohio the death certificate is a electronically generated legal document that is filed in each county of death. Please contact us for a printed worksheet to aid in the completion of the death certificate. Each county health department sets the fee for certified copies.
DEATH CERTIFICATE COPY FEE SCHEDULE: (OHIO COUNTIES)
Greene- $24.00
Montgomery- $22.00
Clinton- $22.00
Fayette- $22.00
Clark- $22.00
Highland- $22.00
Brown- $25.00
Adams- $25.00
It is important that all death certificate information is accurate. There will be a charge for any corrections on death certificates as a result of client funeral home errors and/or omissions. Please check and proof all death certificate information prior to transmission to Storer Mortuary Transport for death certificate preparation.
DEATH CERTIFICATE CORRECTIONS:
OHIO: Notary affidavit must be completed for all corrections if death certificate is filed. The original death certificate is not corrected. There will be a fee for the affidavit certificate.
The Michael Anthony Storer Living Trust DBA Storer Mortuary Transport
Alpha & Omega 2011
