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At Need Arrangements Vital Statistics Form

In this section

At Need Arrangements

Step 1 - Submit this At Need Arrangements Vital Statistics Form

This information is required by the State of Florida to register a death. If you do not know the information type "unknown".

Vital Statistics

A. Information about the deceased

Last Name

First Name

Middle Name (a response is not required if the deceased did not have a middle name)

Maiden Name (required only if a female decedent was ever married)

Sex

Deceased's Legal Residence

Street

City

State/Province

ZIP/Postcode

Father's First Name

Father's Middle Name (not required if no middle name or middle name unknown)

Father's Last Name

Mother's First Name

Mother's Middle Name (not required if no middle name or middle name unknown)

Mother's Current Last Name

Mother's Maiden Name

Decedent of Hispanic Origin?

Not Spanish/Hispanic/ChicanoMexican/Mexican-American/ChicanoPuerto RicanCubanOther specify in Comments section below

Comments

Decedent Race

WhiteBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanNative HawaiianAmerican Indian or Alaska Native specify in Comments section belowVietnameseGuamanianChamorroOther Asian specify in Comments section belowPacific Islander specify in Comments section belowOther specify in Comments section below

Comments

Date of birth

Age

City of birthIf unable to establish City of birth at this time, please be sure to have this information available during the Arrangement Conference

OR Country if not USA

State

Date of death

City of death

State of Death

County of death

Location of death

Name of the place of death ( or street address if residence)

Location (if other)

Primary Doctor Name and Phone Number:

Social Security Number

Education

Choose highest level of education completed.

8th or less9 12 no diplomaHigh School Graduate or GED completedSome college no degreeAssociate DegreeBachelor DegreeMasters DegreeDoctorateUnknown

Veteran information

Was the decedent ever in the US Armed Forces?

Yes The deceased was a Veteran of the US Armed Forces

No The deceased was not a Veteran of the US Armed Forces

If Yes, Branch of service

Employment History

Usual occupation (most of life) (Homemaker is an occupation, as is Never Employed.)

Type of business/industry in general terms (e.g., Education, Healthcare, etc.)

Marital Status at time of death

MarriedNever MarriedDivorcedWidowed

Surviving Spouse Name including last name prior to first marriage, if applicable.

Surviving spouse address

Street

City

State/Province

ZIP/Postcode

Informant information

Name and Relationship of the Next of Kin

Street

City

State/Province

ZIP/Postcode

TelephoneAt least one telephone number whether home or cell must be provided

Email Address

B. Type of disposition

Disposition will beThe final disposition of the decedent must be indicated.

If cremation, disposition of ashes

Special Requests and Notes:

Anti-Spam Security Question

If nothing happens when you press the "Submit Information" button, please check the vitals for red text, this indicates a required field that must be filled in before information can be submitted.

Once you have successfully submitted the Vital Information:

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