VITAL FORM Name Email Address County of Death City, Twon or Location of Death and Zip Code Inside City limit? Inside City limit? Yes No Place of Death(Facility Name) If Hospital Sex Sex Female Male Unknown Social Security Number Birth Place Age-Last Brithday(Years) Date of Birth Marital Status Marital StatusSpecify MarriedNever MarriedWidowedDivorced Ever in US Armed Forces? Ever in US Armed Forces? Yes No Surviving Spouse Deceased Residence-State County Street Address Father Name Mother Name Informant name and relationship to deceased Date of Disposition Mailing address of informant Method of Disposition Method of Disposition Burial Cremation Entombment Hospital Disposal Mediacl Donation Other Cemetery or Crematory(Name) Location Funeral Home (Name and Address) Funeral Home (License Number) Funeral Director - Signature (Type Name) Date Signed by Funeral Director Funeral Director(License Number) Date Signed Date of Death Time of Death Date Pronounced Dead Time Pronounced Dead Registrator - Signature (Type Name) For Registrator Only Submit FAMILY OWNED AND OPERATED © Feggins & Feggins Cremation and Funeral Services, LLC. | site by: articdesigns.com| ObitLOGIN