Vital Statistics Information

Deceased Full Name (Include Middle Initial)

Street

City

State/Province

ZIP/Postcode

Place of Birth / City and State

Race / Ethnicity

Date of Birth

Age

Father's Name

Mother's Name (Include Maiden Name)

Marital Status

If married spouse's name (if wife include maiden name)

Occupation for most of working life

In what industry

Veteran

YesNo

Which branch

SSN

Highest Level of Education

Informant / Next of Kin

Informant's Address

Street

City

State/Province

ZIP/Postcode

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Vital Statistic Sheet

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19 East Germantown Pike
| Norristown, PA 19401
| Tel: 1-610-275-2139
|

Affordable Cremation of Montgomery County
| 19 East Germantown Pike
| Norristown, PA 19401
| Tel: 1-610-275-2139
|

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