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Step 3 - Submit this At Need Arrangements Vital Statistics Form

All areas must be completed. Your form will not be submitted until all questions are answered.

Vital Statistics

A. Information about the deceased

Last Name

First Name

Middle Name (a response is not required if the deceased did not have a middle name)

Maiden Name (required only if a female decedent was ever married)

Sex

Deceased's Legal Residence

Street

City

State/Province

ZIP/Postcode

Father's First Name

Father's Middle Name (not required if no middle name or middle name unknown)

Father's Last Name

Mother's First Name

Mother's Middle Name (not required if no middle name or middle name unknown)

Mother's Current Last Name

Mother's Maiden Name

Decedent of Hispanic Origin?

Not Spanish/Hispanic/ChicanoMexican/Mexican-American/ChicanoPuerto RicanCubanOther specify in Comments section below

Comments

Decedent Race

WhiteBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanNative HawaiianAmerican Indian or Alaska Native specify in Comments section belowVietnameseGuamanianChamorroOther Asian specify in Comments section belowPacific Islander specify in Comments section belowOther specify in Comments section below

Comments

Date of birth

City of birthIf unable to establish City of birth at this time, please be sure to have this information available during the Arrangement Conference

OR Country if not USA

State

Date of death

City of death

State of Death

County of death

Location of death

Name of the place of death ( or street address if residence)

Location (if other)

Social Security NumberIf you choose not to provide the SS Number at this time, you must bring it with you to the Arrangement Conference.

Education

Choose highest level of education completed.

8th or less9 12 no diplomaHigh School Graduate or GED completedSome college no degreeAssociate DegreeBachelor DegreeMasters DegreeDoctorateUnknown

Veteran information

Was the decedent ever in the US Armed Forces?

Yes The deceased was a Veteran of the US Armed Forces

No The deceased was not a Veteran of the US Armed Forces

If Yes, Branch of service

Employment History

Usual occupation (most of life) (Homemaker is an occupation, as is Never Employed.)

Type of business/industry

Marital Status at time of death

MarriedNever MarriedDivorcedWidowed

Surviving Spouse Name including last name prior to first marriage, if applicable.

Surviving spouse address

Street

City

State/Province

ZIP/Postcode

Informant information

Name of person in charge

Street

City

State/Province

ZIP/Postcode

Home TelephoneAt least one telephone number whether home or cell must be provided

Cell phone

Email Address

B. Type of disposition

Disposition will beThe final disposition of the decedent must be indicated.

If cremation, disposition of ashes

Anticipated Ceremonies

C. Preparation and viewing

Viewing/Embalming Preference

Open Casket Visitation (embalming required)No Viewing (embalming not required)Transportation via common carrier (i.e., air cargo embalming required)Use option required by disposition

(Unless embalming is required by the type of service chosen, remains will be sheltered in a cooler as required by Florida law.

I authorize Griffith-Cline Funeral and Cremation Services to embalm

YesNoWill advise later decision must be made within 24 hours following death

Name of authorizing person

Relationship to deceased

D. Funeral/memorial service information

Preferred place of service

Religious denomination

Are there pre-need funeral arrangements on decedent?

YesNoDon't Know

If yes, specify type if knownPlease provide contract number if possible.

Memorials & donation preferencesPlease list memorials or charitable donations that you'd like listed in the obituary

Special instructionsUse the area above to provide additional information or instructions to us.

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