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FAMILY INFORMATION SHEET
The Decedent's Information
First, Middle, and Last Name
Gender
Date of Birth
Date of Death
Ever in Military?
Yes
No
Age
Approximate Weight
City, State and County of Birth
Social Security Number
Place of Death
Residence
Hospital Inpatient
Hospice
ER/Outpatient
Other
Deceased Full Address (Must Include County & Zip Code)
City Limits?
Yes
No
Marital Status
Married
Divorced
Never Married
Widowed
Spouse or Widows Full Name(females must use maiden name)
Father's First, Middle and Last Name
Mother's First, Middle Name and Maiden Last Name
Primary Doctor Name
Doctor Telephone
Time of Death (Include AM/PM)
Decedent's Education
High School
Some College
Associate Degree
Bachelors Degree
Masters Degree
Doctorate
9-12 No Diploma
8th Grade or Less
Occupation (Retired is NOT Acceptable)
Industry
Hispanic Origin
Yes
No
Specify Race
Information About You
Informant's Name ( Legal Next of kin listed on Death Certificate )
Relationship Determined in this order ( Spouse > Child > Parents> any other Blood relative > other. ) If child or sibling Majority must Sign Authorization. Please call for further Information.
Informant's Full Address
Telephone
Informant's Employer and Telephone
Email
Anything Else We Need To Know?
I agree that the information above is accurate. I assume all responsibilities and/or fees if changes to the death certificate are necessary. I understand that providing False information and/or Falsely claiming I am the Legal Next Of Kin is Punishable by Law. I have researched CRS 15-19-106 and understand this statute.
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Agree
Printed Name
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Signature
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