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Required Information for a Death Certificate

Please Have Informant Fill Out information: Death Certificate Vital Information

If you have any questions, or would like assistance with this form, please call 228-467-9031

Death Certificate Vital Information Form

Decedent's Legal Name

Race

Other :

Gender

Age at Last Birthday

Date of Birth

Birthplace

Decedent's Education

Marital Status

If Married- Spouse’s Name

Decedent Of Hispanic Origin:

Yes

No

Was Deceased Ever In U.S. Armed Forces?

Yes

No

Decedent’s Social Security Number

Decedent’s Usual Occupation

Industry or Business of Decedent's Occupation

Decedent's Address

County

City

State

Zip Code

Residence In City Limits

Yes

No

Father's Name

Mother's Name PRIOR To First Marriage

Informant's Name

Relationship

Informant's Mailing Address

Cemetery

Location

Number of Death Certificates Requested

Information Provided By

Free Text

Who is submitting this form? Please fill out the fields below.

Name

Phone Number

Email Address

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