Vital Statistics Form

Do not abbreviate. Check spelling if you are not certain. Be careful, errors or omissions may delay processing of death certificates.

Please complete the following information to the best of your knowledge. If you have questions, please call (404) 355-7627.

Deceased Information(Required)

First Middle Last

Last Name at Birth (If Female)

Date of Death

Social Security Number

Age(Required)

Race

Enrolled Tribe

If American Indian or Alaska Native, enter name of the enrolled or principal tribe.

Date of Birth

Place of Birth (City and State)

Deceased Most Recent Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Inside City Limits?

Country

Armed Forces Branch:

Rank

Other

Work

Occupation

(For most of working life)

Employer

Name of last known, if retired.

Industry

Name of last known, if retired.

Marital

Marital Status

Date of Marriage

Name of Spouse

(Indluding Maiden Name if applicable )

Family

Name of Father

Name of Mother (Maiden Name)

Education

Education Level : (Last Grade if did not graduate high school)

Your Information

First Middle Last

Relationship to Deceased(Required)

Other

Please describe.

Home Phone(Required)

Cell(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County

The County of the state you reside in.