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Vital Statistics
Leap Tie - Office
2021-08-23T16:24:32-04:00
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
MM slash DD slash YYYY
Social Security Number
Number of Death Certificates Needed:
Age
(Required)
Race
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Island
Other
Unknown
Enrolled Tribe
If American Indian or Alaska Native, enter name of the enrolled or principal tribe.
Date of Birth
MM slash DD slash YYYY
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?
Yes
No
Unknown
County
The County of the state they resided in.
Country
Armed Forces Branch:
None
Army
Navy
Air Force
Marines
Other
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
Married
Married, but legally separated
Divorced
Widowed
Never Married
Unknown
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)
High School Graduate or GED
Some College
Associate
Bachelors
Masters
Doctorate
Your Information
(Required)
First
Middle
Last
Relationship to Deceased
(Required)
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.
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