Vital Statistics Form Page 2
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1
2Military Service:
Yes / No
Serial Number:
__________________________
Date of Induction:
__________________________
Branch of Service:
__________________________
Highest Rank Achieved:
__________________________
Wartime Service:
Yes / No
What war?
__________________________
Honorable Discharge:
Yes / No
Informant’s Name: ______________________________________________________
(Person’s name providing information for death certificate)
Informant’s Relationship to Deceased: ________________________________________
Informant’s Address: _____________________________________________________
Informant’s Phone Number: ________________________________________________
Type of Disposition (Burial, Cremation, Donation etc.): __________________________
Place of Disposition (Name of Cemetery, Crematory or Institution):
________________________________________________________________________
Location of Place of Disposition (Address, City, State, Zip):
________________________________________________________________________
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