Death Certificate information sheet for Century Cremation & Funeral Services Inc. 

Please complete form and fax 212-342-0164 or email to jack_63@sprint.blackberry.net 
Date: Funeral home Case # 
Deceased Name: 
Place of Death: 
Telephone: 
Date of Death: 
Time of Death: 
County of Death: 
Country: 
Deceased Address: 
APT: 
City: 
State: 
Zip code: 
Deceased City of Birth: 
State: 
Deceased Ancestry: 
Sex: 
Race: 
Date of Birth: 
Age: 
Social Security #: 
Honorable Veteran yes/no: 
Dates of services from: to: 
Education Level (1-12): 
College (degrees if any): 
Occupation (DO NOT ENTER RETIRED): 
Industry of Work: 
Location/name of business: 
Father's Name: 
Mother's First and MAIDEN NAME: 
Marital Status: 
Name of surviving spouse: (if wife, name prior to marriage) 
Informant's name: 
Relationship to Deceased: 
Telephone: 
FAX: 
Address: 
APT: 
City: State: 
Zip: 
Email address: 
Number of Death certificates ordering: 

I have reviewed the above information given by me to the funeral director, and to the best of my knowledge 
this information is correct. If any errors or mistakes found thereafter it will be my responsibility to correct 
and to pay any fees affiliated to make such correction, and not the funeral home. 

SIGNATURE OF INFORMANT (X) _________________________________ Date______________