Vital Statistics Form

Vital Statistics

This form will be used to complete death certificate. All required items are identified with an asterisk. If you do not have the complete information, please type unknown in the field and we will get the information at a later time.

Full Legal Name of Deceased:

First Name (of deceased)

Middle Name (of deceased)

Last Name (of deceased)

Maiden Name (of deceased)(if applicable)

Date of Birth (of deceased)

Date of Death (of deceased)

City of Birth (of deceased)

State / Country of Birth (of deceased)

Full Legal Name of Deceased's Mother:

First Name (of deceased's mother)

Middle Name (of deceased's mother)

Maiden Name and Last Name (of deceased's mother)

Full Legal Name of Deceased's Father:

First Name (of deceased's father)

Middle Name (of deceased's father)

Last Name (of deceased's father)

Social Security Number of Deceased

Marital Status

Full Legal Name of Spouse (if applicable):

First Name (of deceased's spouse)

Middle Name (of deceased's spouse)

Maiden Name and Last Name (of deceased's spouse)

Last Occupation(DO NOT PUT RETIRED)

Industry and Name of Business

Did the decedent ever serve in the armed forces?

YesNo

If yes, what branch?

Do you have a copy of Military Honorable Discharge Papers?

YesNo

(If a Veteran)

Upload Honorable Discharge Papers (DD-214)(If a Veteran)

Ethnicity

Highest Level of Education

Home Address of Deceased:

Street

City

State/Province

ZIP/Postcode

Name of Informant:

First Name of informant

Middle Name

Last Name

Home Phone

Email Address

Cell Phone

Relationship to Decedent

Home Address of Informant:

Street

City

State/Province

ZIP/Postcode

Number of Death Certificates Requested** Remember that there is no suggested number of death certificates. We recommend that you request a few extra copies in case something comes up.

I confirm I have read the contents of this form and that the above information that I have provided is correct and true. I do not hold the representatives of Bryce Funeral Home responsible if this information is not correct.

I agree

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Our Locations

Bryce Funeral Home Inc.
| 276 Pawling Avenue
| Troy, NY 12180
| Tel: 1-518-272-7281

DeGraaf-Bryce Funeral Home, Inc.
| 4392 US 150
| West Sand Lake, NY 12196
| Tel: 1-518-674-5790
| Fax: 1-518-273-9345

Bryce Funeral Home Inc.
| 276 Pawling Avenue
| Troy, NY 12180
| Tel: 1-518-272-7281

DeGraaf-Bryce Funeral Home, Inc.
| 4392 US 150
| West Sand Lake, NY 12196
| Tel: 1-518-674-5790

A year of daily grief support

Our support in your time of need does not end after the funeral services. Enter your email below to receive a grief support message from us each day for a year. You can unsubscribe at any time.