Family Information Sheet

VITAL RECORDS WORKSHEET

STATE OF COLORADO
DECEDENT'S NAME*
FIRST, MIDDLE, LAST
Gender*

MaleFemale
Date of Death

MonthDayYear
Date
Age
Date of Birth*

MonthDayYear
Date
Birthplace*
City and State or Foreign Country or Unknown
Was decedent ever in US Armed Forces*

YESNO
Place of Death*

InpatientER/OutpatientDOAAssisted Living/Nursing HomeHospiceDecedent's ResidenceOther
Facility Name(if not institution, give street and number)
City or Town, State , Zip Code or Location of death (if not at a Facility)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Death*
Occupation (Type of work done during most of working life.Do NOT use retired)*
If not known type in Unknown
Kind of Business/Industry*
If not known type in Unknown
Marital Status*

MarriedWidowedUnknownNever MarriedDivorced
Spouse or Widows Full Name( if wife use maiden name)
Decedent Address

Street Address

Street Address Line 2

CityState

Zip Code
County*
Inside City Limits

YESNO
Was Decedent of Spanish Orgin*

NOYES, Puerto RicanYes, Mexican/Mexican-American/ChicanoYes, CubanUnknownNot ObtainableRefusedYES, Other Spanish/Hispanic/Latino (Specify below)Other
Decedent's Race*
Education*

Eighth Grade or Less9th - 12th grade, but no diplomaAssociates DegreeHigh School Diploma or GED completedSome College Credit, but No DegreeBachelors DegreeMaster's DegreeDoctorate or Professional DegreeNoneUnknown
Father's Name (First, Middle, Last)*
If not known type in Unknown
Mother's Name (First, Middle, MAIDEN)*
If not known type in Unknown
Informant's Name and (relationship to deceased) *
Email
example@example.com
Phone Number*

Area CodePhone Number
By my/ our signature(s) below, I/we attest to the accuracy of the above information to be sent to the Colorado State Vital Records Office by Simply Cremation. Any corrections to data or the reissue of corrected certificates may incur a cost which must be paid by the family of the deceased or the party that requests the correction and/or new certificates.
Printed Name *
Signature*

Clear
Should be Empty:

VITAL RECORDS WORKSHEET