title titleMRSMISSMSOR

Name

Email Address

1a. Last 1b. First 1c. Middle Name of Decedent

2a. Date of Death

2b. Hour of Death

3. Gender 3. GenderMaleFemale

4. Race 4. RaceBlackWhiteHispanicAsianOther

5. Marital Status 5. Marital StatusMarriedNever MarriedWidowedDivorced

6. Surviving Spouse (if Wife, give Maiden Name)

7. Date of Birth

8a. Age Years

8b. Age Under 1 year (Months - Days)

8c. Age Under 1 Day (Hours - Minutes)

9.Birthplace (City and State or Foreign Country)

10. Usual Occupation (kind of work done most)

11. Kind of Business or Industry

12. Of Hispanic Origin? 12. Of Hispanic Origin? Yes No

13. Ever in U.S. Armed Forces? 13. Ever in U.S. Armed Forces? Yes No

14. Social Security Number

15. Decedent's Education (Highest completed)

16a. Place of Death 16a. Place of Death Hospital Inpatient Hospital ER/Outpatient Hospital DOA Non-Hospital Nursing Home Residence Other

16b. Name of Facility (if not in Facility, give street address or location)

16c. Place of Death in City Limits? 16c. Place of Death in City Limits? Yes No

17a. City, Town or Location of Death

17b. Parish of Death

18a. Residence Street Address (if rural specify rural route number or location)

18b. Parish of Residence

18c. State of Residence

18d. Usual Residence of Decedent (City, Town or Location)

18e. Zip Code

18f. Residence Inside City Limits? 18f. Residence Inside City Limits? Yes No

19a. Father's Last Name First Middle

19b. Father's Place of Birth 19c State

20a. Mother's Last Name First Middle

20b. Mother's Place of Birth 20c. State

21a. Name of Informant

21b. Informant's Address

21c. Date (Month, Day, Year)

22a. Method of Disposition 22a. Method of Disposition Burial Cremation Removal Other

22b. Date Thereof

22c. Name and Location of Cemetery or Crematorium

23a. Signature and Address of Funeral Director

23b. Facility Number

23c. License Number

24. Alterations