Please provide the following contact information:

1	Decedent's Legal Name	First Middle
		Last Suffix
2	Date of Death	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969
3	Sex	Male Female
4	Age	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 Years If  under 1 year Months 0 1 2 3 4 5 6 7 8 9 10 11 Days 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 If  under 1 day Hours 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Minutes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
5	Social Security #
6	County of Death
	Birth Date	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1968 1967 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
8a	Place of Birth	(City/ Town or County)
8b	Place of Birth	(State of Foreign Country)
9	Decedent Education	8th grade or less 9th -12th grade; no diploma High school graduate or GED completed Some college credit, but no degree Associates degree Bachelors degree Masters degree Doctorate degree Refused Not obtainable Unknown Not classifiable
10	Was Decedent Hispanic in Origin?	No, Not Hispanic Yes, Check all of the following below that apply     Mexican, Mexican-American, Chicano   Puerto Rican   Cuban   Other Spanish/Hispanic/Latino          Specify
11	Decedent Race	White or Caucasian Black or African American American Indian or Alaska Native     Specify                                                                                                              principal tribe(s)     Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian                          Specify            Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander          Specify       Other                                 Specify
12	Served in U.S. armed forces?	Yes No
13	Residence
14	City/Town
15	Residence County
16	State or Foreign Country
17	Zip Code (+4)
18	Inside City Limits	Yes NoUnknown
19	Martial Status at Time of Death	Married Widowed Never married Legally Seperated Divoriced Unknown
20	Spouse's Name
21	Occupation
22	Kind of Business/Industry
23	Father's Name	First Middle Last Suffix
24	Mother's Name (Prior to first marriage)	First Middle Last
25	Informants Name
26	Telephone Number
27	Relationship to Decedent	Wife Husband Mother Father Sister Brother Daughter Son Other     If other please specify relationship
	Mailing Address
	Place of Death
	Facility Name
	Location of Death Street Address
	City /Town
	State
	Zip Code (+4)