Vital Statistics Form

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YOUR INFORMATION

Funeral Home

First Name

Last Name

Email

Phone

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YOUR INFORMATION

First Name

Last Name

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Physical Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

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Mailing Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

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Deceased's Information

First Name

Middle Name

Last Name

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Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Date of Death

Authorizing Person

Did the death occur from a disease declared by the Department of Health and Human Services to be infectious, contagious, communicable, or dangerous to the public health?

Yes

No

Check any that are present in body of the deceased:

Pacemaker

Defibrillator

Silicone Implants

Radioactive Implants (including “seeds”)

Plastic cast(s)

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All pacemakers, prostheses, plastic casts, and radioactive implants must be removed prior to delivering the deceased to the crematory.

Eventually the cremated remains will be interred or inurned in a cemetery or will be scattered:

Yes

No

Deceased will be transported to Oak Grove Crematory in the following type of container/casket:

A temporary container

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If the cremated remains are not being interred at the cemetery, then the staff at the crematory is requested by the authorizing person to make the following disposition of the cremated remains:

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Ship by registered mail to

Address

City

State

ZIP / Postal Code

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Deliver by vehicle before

Date

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Address

City

State

ZIP / Postal Code

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Pick up at Oak Grove Crematory

Party Responsible for Pick Up

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Address

Street Address

Address Line 2

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