Vital Statistic Information

All the information that is gathered in this form, is required to properly complete the State of Connecticut death certificate.

Full Legal Name:

Date of Birth:

Place of Birth (City and State):

If born outside the U.S. please list country:

Full address of Legal Residence:

Social Security Number:

Occupation prior to retirement(Type of work):

Name of Business or type of industry:

Father's Full Name:

Mother's maiden name:

Marital Status:MarriedMarried, but separatedWidowedDivorcedNever Married

If married, spouse's maiden name:

Highest level of education:8th Grade or LessHigh School Graduate/GEDAssociate's DegreeBachelor's DegreeMasters Degree9th-12th Grade, No DiplomaDoctorate or Professional DegreeSome college credit, but no degreeUnknown

Armed Forces: Yes No If yes, Branch: ArmyAir ForceCoast GuardMarine CorpsNavyConflict:

Race:WhiteBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther Asian(specify)American Indian(Specify Tribe)Alaska Native(Specify Tribe)Native HawaiianGuamanian or ChamorroSamoanOther Pacific Islander(Specify)Other (Specify) Specify:

Of Hispanic origin:NoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latino(Specify) Specify:

Primary Care Physician Name:

Primary Care Physician number:

Primary Care Physician address:

This Next section of questions is about the Legal Next of Kin/Informant.

Name:

Relationship:

Best Contact Number:

Email Address:

Full address of Legal Residence:

Mailing address if different:

Would you like to receive a confirmation email or phone call? Yes No

If yes, please enter your email or phone number: