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Vital Information Worksheet

We offer an efficient online option for you to prepare and submit the Vital Information we need in order to complete the Death Certificate. 

WHEN SO ADVISED BY YOUR FUNERAL DIRECTOR, PLEASE COMPLETE THE ONLINE WORKSHEET BELOW. Certain fields are required. When complete, be sure to enter the "Anti-Spam code" provided and then click the "Submit" button at the bottom of the form! 

PLEASE NOTE: The information provided must be as complete and as accurate as possible. This information will be used to create the Death Certificate, which is a legal document.

* Required
DECEDENT FIRST NAME: *
DECEDENT MIDDLE NAME: *
DECEDENT LAST NAME: *
SUFFIX, if applicable:
DECEDENT ADDRESS: *
DECEDENT CITY/STATE/ZIP: *
Is This Address WITHIN CITY LIMITS of that City? *
Yes    No   
DECEDENT CITIZENSHIP: *
USA    Other(Please indicate OTHER CITIZENSHIP in Next Box)    
CITIZENSHIP: If other than USA, please indicate OTHER CITIZENSHIP here:
EDUCATION: [# Years Completed] *
EDUCATION: [Highest Degree Completed]
GED    HS Diploma    Some College, No Degree    College 2 Year Degree    College 4 Year Degree    College Master's Degree    College Doctoral Degree   
SS # [While this is necessary information, you can provide by phone or in person if you prefer]:
GENDER: *
Male    Female   
RACE: *
MARITAL STATUS: *
Single    Married    Widowed    Separated    Divorced    Never Married   
MARRIAGE CLASSIFICATION: If Married: Is the Marriage considered a Common Law Marriage? *
No    Yes   
SURVIVING SPOUSE: If Spouse Survives, Please Indicate Spouse's Name (Include Last Name PRIOR TO ANY MARRIAGE in parentheses) e.g., Susan Rebecca Smith (Jones)
SURVIVING SPOUSE ADDRESS: Is Surviving Spouse's Address The Same As Decedent's Address? *
Yes    No    N/A   
SURVIVING SPOUSE ADDRESS: If Surviving Spouse's Address is DIFFERENT FROM DECEDENT'S ADDRESS, Please list Surviving Spouse's Address HERE:
DATE OF BIRTH: *
PLACE OF BIRTH: *
DATE OF DEATH:
PLACE OF DEATH:
FATHER'S FIRST NAME: *
FATHER'S MIDDLE NAME:
FATHER'S LAST NAME: *
MOTHER'S FIRST NAME: *
MOTHER'S MIDDLE NAME:
MOTHER'S LAST NAME: *
MOTHER'S MAIDEN NAME BEFORE ANY MARRIAGE: *
DECEDENT'S USUAL OCCUPATION MOST OF LIFE [Do Not Use "Retired"]: *
TYPE OF BUSINESS/INDUSTRY [Do Not Use "Retired"]: *
WAS DECEDENT A MILITARY VETERAN?
Yes [Please provide Form DD-214 Discharge Papers]    No   
MILITARY VETERAN: If "YES", please indicate Branch of Service
Army    Navy    Air Force    Marines    Coast Guard    Merchant Marines   
CEMETERY: Please Indicate CEMETERY NAME and CITY/STATE OF CEMETERY here if known:
INFORMANT [Person Completing This Form]: *
INFORMANT RELATIONSHIP TO DECEDENT: *
INFORMANT MAILING ADDRESS: *
INFORMANT CITY/STATE/ZIP: *
INFORMANT PHONE NUMBER(S): *
INFORMANT EMAIL ADDRESS:
DO YOU ALREADY KNOW HOW MANY CERTIFIED COPIES OF THE DEATH CERTIFICATE YOU WISH TO ORDER? *
Yes    No    I'll Need More Information To Make This Decision   
IF YES, PLEASE INDICATE THE NUMBER OF CERTIFIED COPIES YOU DESIRE:
IF ORDERING CERTIFIED COPIES AT THIS TIME, PLEASE INDICATE HOW YOU WOULD LIKE TO RECEIVE THEM:
MAIL TO THE INFORMANT at the mailing address provided    HOLD THEM AT THE FUNERAL HOME so I can pick them up myself    I WILL CONTACT WEERTS FUNERAL HOME to arrange this   
Please type the number 26235:
(spam prevention)

For further information, just go to our Contact Us page and send us an email, or call us anytime at 563.355.4433. 

Someone is always available to assist you.  
 
We'll be here when you need us.
Weerts Funeral Home - 3625 Jersey Ridge Road, Davenport, Iowa 52807 tel. 563.355.4433