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The information below is being collected to complete the death certificate. Please note that this form is not a means of notifiying us if a death has occured. In the event of an emergency, please call our offices at 203-269-6484. If you would prefer to make these arrangements together in person, please contact us and we would be happy to make arrangements to do so.

Please complete the following. All information being collected is data pertaining to the person whose services are being arranged. If you are completing this on behalf of someone else, your information will be collected at the very bottom.

These arrangements are for: *

Myself Someone else

If someone else, their relation to you: *

Has a death occurred? *

Yes No

Full legal name *

Decedent's gender *

Male Female

Decedent's age last birthday *

Date of birth *

City and state of birth or foreign country *

Decedent's address *

Line 1

Line 2

City

State

Zip Code

Country

Was decedent ever in the armed forces? *

Yes No Unknown

Decedent's marital status at time of death *

Married Married but separated Widowed Divorced Never married Unknown

If married, spouse's name (Give full name prior to first marriage) *

Decedent's father's name (first, middle, last) *

Decedent's mother's name prior to first marriage (first, middle, maiden) *

Decedent's education *

8th grade or less 9th - 12th Grade, No Diploma High School Graduate/GED Some College Credit, No Degree Associate Degree Bachelor's Degree Master's Degree Doctorate or Professional Degree Unknown Not Available

Was decedent of Hispanic Origin? *

Race *

Decedent's usual occupation *

Decedent's kind of business/industry *

Decedent's social security number *

Name of person providing this information (informant) *

Informant's relationship to the decedent *

Informant's address *