Vital Statistics

N.Y.C. Funeral & Cremation Service Inc.

VITAL STATISTICS: Additional charge will be required if any changes are made after this sheet is submitted to us, or due to incorrect information. All fields are required.
(Do not use autofill on computer)

Are you the legal next of kin that has the authority to control the disposition (Cremation) of the remains of the Deceased?
Yes No

What is your relationship to the Deceased?

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement. If I am signing on behalf of another individual, I attest that I have the authority to do so.

Signature Draw Signature

Name of Deceased (Decedent):
Deceased (Decedent) Legal Address: (include apt. number, st, city, state, zipcode)
(Apt. number, st)
(City): (State): (Zip):
Date of Birth:
Place of Birth (City, State or Country)
Date of Death:
Place of Death: (City): (State):
Hospital or Nursing Home or Residence where person Died:
Social Security Number (if you do not know social security-enter all zeros):
Estimated weight (lbs.) of Decedent [Numbers Only, No Letters!]:
Occupation [Job they did when working]: (Do not enter “Retired”)
Type of Industry:
Highest Level of Education: (8th grade or less, 9-12 no diploma, H.S, Some College no degree, BA, MA, Ph.D, Unknown)
Gender: Male Female
Veteran: Branch of Service:
For NYC deaths, you must submit the original DD214 Honorable Discharge Paper in order to have veteran status on the death certificate.
Name of Spouse: (Including Maiden Name)
Marital Status: (Never Married, single, married, divorced, widow etc)
If legally married, spouse is next of kin and must sign.
Hispanic or non-Hispanic:
Race as defined by US census: White, Black or African American, other- Specify
Father’s Name: (First and Last Name)
Mother's Name: (First and Last include Maiden Name)
Next of Kin: Relationship:
Next of Kin Legal Address: (include apt. number, st, city, state, zipcode)
(Apt. number, st)
(City): (State): (Zip):
Home#: Cell Phone:
Email:

I agree that all above information is correct. I certify that I am the legal next of kin of the Decedent.

Name of Person Signing:
Signature Draw Signature
Date Signed:

If you are done filling data into all fields, please submit the form (once submitted information can not be edited)

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