Vital Form StatisticsPlease enable JavaScript in your browser to complete this form.Referred By:Case #(This form must be typed or printed clearly)Deceased First NameDeceased Middle NameDeceased Last NameDeceased SuffixSexDateTimeSocial Security #AgeDate of BirthArmed ForcesYesNoBranchPlace of DeathCityStateCountySelect below:HospitalResidenceHospiceNursing Home/Assisted LivingOtherCityInside City LimitsYesNoCounty of DeathOccupation(Do not use retired)Business:(Type of Business, i.e. factory, homemaker, etc)Marital StatusMarriedNever MarriedWidowedMarried/SeparatedDivorcedSpouseResidenceState:CountyYesInside City Limits:NoCityZipHispanic or Haitian Origin: If Yes: (Specify)American Indian or Alaska NativeAsianBlack or African AmericanWhiteEducation8th Grade or LessHigh SchoolDegree (AS, BS, MA. PHD)OtherMothers First NameMothers Middle NameMothers Last NameMothers SuffixFathers First NameFathers Middle NameFathers Last NameFathers SuffixInformant's NameAddress:PhoneRelationshipThis form is used to complete the death certificate, which is a legal document and filed with the State of Florida. It is therefore important to fill completely and accurately with the proper spelling of names and places. Corrections to the death certificate require 6 8 weeks and there are fees that apply. / certify that to the best of my knowledge that all information provided is true and correct. Signature of person completing form xSignature of person completing formClear SignatureSubmit
