Statistical Information For Funeral Home Records, Georgia Death Certificate/ Permits
ect..
Full Name
Maiden Name if Female
Sex
Race
Origin (
American/Mexican/French,
ect)
Date of Birth
State, City and County of Birth
Citizen of what
Country
Deceased
Marital Status
Education Level
4Yr
College, 2Yr College, High school, Elementary School
Spouse (
If married or widowed, give spouse's-If
wife , give maiden Name)
Was deceased in the Armed Forces
Social Security Number
Usual Occupation Job Title
Kind of Industry
Employer's Name
Resident-State
County
City
Street Address
Inside
City Limits
Fathers Full Name
Mothers Full Name
Mothers Maiden
Name
Next of Kin Name
Relationship
Burial or Cremation or Removal from State
Name of Cemetery
City and State Cemetery is located in
Survivors
Your Name
Your Phone Number
Survivor Information
Relationship
Number of Grandchildren
Number of Great Grandchildren
Number of Great Great Grandchildren
Funeral Service
Details
Please note no date of service or time is
set on this form. You will need to speak with your Funeral Director prior
to scheduling a day and time.
Type of Service You Prefer
Note: Date and time
of service will be set at Arrangement Conference
If the services is not in the Funeral Home Chapel Please provide us
with the Name, Address and Phone number of service location
Visitation
Preference Open or Closed Casket
Name of Clergy or Speaker's
Musical Selections
Will the funeral home need to provide a Organist or pianist
Will the funeral home need to provide a
Your Soloist Name
Pallbearers
Honorary Pallbearers (
Sunday School Class,
Rotary Club ect..)
Military Honors
You must provide a DD214 or proof of
military service to qualify for Military Honors and a flag
Branch of Service