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Vital Statistics Information

Full Legal Name of Deceased

Sex

MaleFemale

If Female, Maiden Name (Name before she married)

Date of Birth

City & State or City & Foreign Country of Birth

Social Security Number

Race

Was Decedent in US Armed Forces

YesNo

Was Decedent ever a Peace Officer (Police Officer) in Texas

YesNo

Education

8th Grade or Less

9th-12th, No Degree

High School Graduate or GED

Some College, No Degree

Associate

Bachelor's

Master's

Doctorate

Marital Status

MarriedNever MarriedWidowedDivorced

If Married, Surviving Spouse's Full Name ( include maiden name, if wife)

Decedent's Usual Occupation During Most of Life

Kind of Business or Industry

Decedent's Residence Street Address:

Street

City

State/Province

ZIP/Postcode

Is Residence Inside City Limits

YesNo

Decedent's Father's Name

Decedent's Mother's Full Name (including maiden name)

Name & Relationship of Informant

Mailing Address of Informant:

Street

City

State/Province

ZIP/Postcode

Phone Number of Informant

Number of Certified Copies of Death Certificates:

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