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If a Death Has Just Occurred
Online Preplanning Form
Free Text
Personal Information
Decedent's Legal Name (First, Middle, Last) (include AKA's if any)
If Female, Decedent's Last Name Prior to First Marriage
Sex
Social Security Number
Date of Birth
Birthplace (City and State or Foreign Country)
Marital Status
Married
Widowed
Never Married
Married but Separated
Divorced
Unknown
Surviving Spouse (if wife, give name prior to first marriage)
Decedent's Usual Occupation (kind of word done during most of working life.) (Do not use retired)
Kind of Business/Industry
Was Decedent Ever in U.S. Armed Forces
Yes
No
Residence-State
County
City or Town
Street and Number
Zip Code
Inside City Limits
Yes
No
Decedent's Education (Check the box that best describes the highest degree or level of school completed at the time of death))
8th Grade or Less
9th-12th Grade; No Diploma
High School Graduate or GED Completed
Some College Credit but No Degree
Associates Degree (e.g., AA, AS)
Bachelor's Degree (e.g., BA, AB, BS)
Master's Degree (e.g., MA, MS, MEng, MSW, MBA))
Doctorate (e.g., PhD, EdD) or Professional Degree (e.g., MD, DDS, DVM, LLB, JD)
Decedent of Hispanic Origin (Check box that best describes whether the decedent is Spanish/Hispanic/Latino. Check "No" box if the decedent is not Spanish/Hispanic/Latino.)
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Pueto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
Specify
Decedent's Race (Check one or more races to indicate what the decedent considered himself or herself to be)
White
Black or African American
Native Hawaiian
Chinese
Filipino
Japanese
Guamanian or Chamorro
Korean
Vietnamese
Samoan
Other Asian (Please Specify)
Other Pacific Islander (Specify)
Other (Specify)
American Indian or Alaska Native (Name of the enrolled or principal tribe)
Father's Name (First, Middle, Last)
Mother's Name Prior to First Marriage (First, Middle, Last)
Informant's Name
Relationship to Decedent
Mailing Address (Street and Number, City, State, Zip Code)
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