Form Sfn 58647 - Funeral Directors Worksheet For Completing A Facts Of Death Record Page 2

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SFN 58647 (10-2013)

Page 2

24. Decedent of Hispanic Origin (Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check NO if the decedent is not

Spanish/Hispanic/Latino.

Yes, Other Spanish/Hispanic/Latino - Specify:

No, Not Spanish/Hispanic/Latino

Yes, Puerto Rican

Yes, Mexican, Mexican American Chicano

Yes, Cuban

25. Decedent's Race - Check one or more races to indicate what the decedent considered himself or herself to be.

White

Vietnamese

Black or African American

Other Asian - Specify:

American Indian or Alaska Native

Native Hawaiian

- Name of Principal Tribe:

Guamian or Chamorro

Asian Indian

Samoan

Chinese

Other Pacific Islander - Specify:

Filipino

Other - Specify:

Japanese

Unknown

Korean

26. What is the Decedent's Ancestry - Check one or more races to indicate what the decedent considered himself or herself to be.

Native American Indian

French

Other Eastern European (i.e. Russian)

English/Welsh

Scandinavian (Norwegian, Danish, Swedish)

Other Northern European (i.e. Finnish)

Irish

Polish

Other - Specify:

German

Other Western European (i.e. Belgian)

Refused/Unknown

27. Decedent's Usual Occupation (Indicate the type of work done during most of the decedent's working life, DO NOT USE RETIRED, e.g. High School

Teacher, Airman 1st Class, Electronic Assembler)

28. Business or Industry Where the Decedent Usually Worked (e.g. High School, Hospital, Air Force, Manufacturing - Computers, Retail - Department Store,

Grocery Store)

29. Signature of Funeral Director

30. License Number

31. Name of Funeral Home

Date of Signature

Address

City

State

ZIP Code

32. Telephone Number

33. Fax Number