Basic Vitals

Required Basic Vital Statistic Information

This information is essential to begin the documentation and death certificate process. Please complete as many fields as possible. If you’re missing any details, you may skip them for now and provide the information by phone or email later. Please note that we cannot initiate the documentation process without ALL of the required information.

Basic Vitals Form

Deceased First Name

Deceased Middle Name

Deceased Last Name

Most Recent Address of Deceased

City

State

Zip Code

Ethnicity

Marital Status

Date of Birth

Birthplace

Father's First Name

Father's Last Name

Mother's First Name

Mother's Last Name

Usual Occupation

Social Security Number

Branch of Military if Veteran

Surviving Spouse's First Name

Surviving Spouse's Middle Name

Surviving Spouse's Last Name

Informant or Next of Kin Name

This is the name and address that will appear on the death certificate of the person responsible for arrangements.

Street Address of Next of Kin / Informant

City

State

Zip Code

Email Address

Phone Number

Number of Death Certificates Requested

Cozart Funeral Home

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Basic Vitals﻿

Required Basic Vital Statistic Information

Basic Vitals Form

Cozart Funeral Home

Basic Vitals