Vital Statistics Form - Affordable Cremation Services of New York Affordable Cremation Services of New York

If You Are in Immediate Need Call Affordable Cremation Services of New York
(516) 279-2881.

If your loved one has just passed, we extend our deepest sympathies to you for your loss. Please call us first and notify us that a death has occurred. Completing this form does not notify us immediately.

Begin Form:

Information About the Person Completing This Form

First Name*

Last Name*

Your Address

Street Address City State ZIP Code

Email*

Phone

Person for whom I am filling for:*

Deceased Vital Statistics for Death Certificate

Deceased First Name*

Deceased Last Name*

Race

Spanish Decent?

Gender

Have a Pacemaker/Defibrillator?

Yes
No

Weight of Deceased

Date of Birth

Place of Birth

City of Death

Deceased Location

Street Address Address Line 2 City State ZIP Code

Location of Death

(Ex: Hospital name, emergency room, name of nursing home, in transit, etc.)

Education

Occupation

Industry

Company

Company Location

Marital Status

Full Name of Surviving Spouse

If Wife, Provide Maiden Name

Residence - Street Address

City

Inside City Limits

County

State

Zip Code

Father's Full Name of Deceased

Mother's Full Maiden Name of Deceased

Type of Disposition

Indicate Preference for Disposition of Ashes

Veteran Information

Was Decendent Ever In the US Armed Forces?

Branch of Serivce

Date Enlisted

Date Discharge

Honorable Discharge

Is a copy of discharge papers available?

Informant/Person In Charge of Information

First Name*

Last Name*

Relationship to deceased

Email Address

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

This field is for validation purposes and should be left unchanged.