Immediate Need | Ferguson Mortuary

This information will be used to complete the official death certificate.

This worksheet is not to be forwarded to the Office of Vital Statistics

DECEDENT'S LEGAL NAME (First, Middle, Last)*

Last Name At Birth (If Female) *

Sex*

Date of Death*

Social Security Number*

Age*

Under 1 Year (Months/Days)*

Under 1 Day (Hrs/Mins)*

Date of Birth*

Birthplace (City and State/Foreign Country)*

Street Address*

City or Town of Residence*

County of Residence*

State of Residence*

Country*

Inside City Limits*

Armed Forces*

Occupation*

Nature of Business*

Employer*

Marital Status*

Spouse's Name (If Wife, Maiden Last Name)*

Father's Name (First, Middle, Last)*

Mother's Name (First, Middle, Maiden)*

Decedent's Highest Education Level*

Informants Name (First, Middle, Last)*

Relationship to Decedant*

Mailing Address*

Hispanic Origin*

Decedent's Race*

If Death Occurred In Hospital

If Death Occurred Other Than In Hospital

Facility Name/Location of Death

Facility/Location Address

County of Death*

Method of Disposition (If known at this time)

Place of Disposition (If known at this time)

Death Certificate Worksheet