Death Certificate Information


Walker Sanderson Tribute Center – Funeral Home and Crematory

*Required fields



*Name of Submitter:
*Email Address of Submitter:
Deceased Information:
*Full Legal Name of Deceased:
*Maiden Name of Deceased:
Address:
City:
County:
State:
Zip Code:
Ethnicity / Race:
Sex:
Education:
Social Security Number:
Date of Birth:
Age:
Birthplace (City, State):
Father’s Name:
Mother’s Maiden Name:
Marriage Information:
Marriage Status:
Spouse Name:
Spouse Maiden Name:
Occupation Information:
Decedent’s Usual Occupation:
Type of Business or Industry:
Veteran or Military Service:
U.S. Military Veteran?
Yes
No
If yes, which Branch of Service:
Next of Kin, or Person Providing Information:
Informant’s Name:
Address:
City:
State:
Zip Code:
Phone Number:
Email Address:
Relationship to Decedent:
Death and Disposition Information:
Date of Death:
Time of Death (24-hour clock):
Place of Death:
If Hospital, please list Hospital name:
Address:
City:
County:
State:
Doctor or Certifier of Death Certificate:
Address:
City:
State:
Phone:
Final Disposition:
Date of Disposition:
Cemetery / Crematory:
City:
Burial Permit, if needed:
Number of Death Certificates Needed: