Why Cremation Center of Kansas City?
Cremation Information
Obituaries
Pets
Contact

Why Cremation Center of Kansas City?
Cremation Information
Obituaries
Pets
Contact

Vital Statistics Form

Please fill this form out as much as possible. It will help us to complete the death certificate. All fields with an asterisk are required.

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First Name

Middle Name or Initial

Last Name

Gender

Male

Female

Address

Apt, suite, etc.

Country

City

State

Zip Code

Date of Death

Place of Death

Address of Place of Death

Apt, suite, etc

Country

City

State

Zip Code

Date of Birth

City of Birth

State of Birth

Social Security Number

Marital Status at Time of Death

Married

Widowed

Divorced

Never Married

Married, but Separated

Unknown

Spouse's First Name

Spouse's Maiden Name

Father's First Name

Father's Last Name

Mother's First Name

Mother's Maiden Name

Education

8th grade or less

9th-12th grade, no diploma

High School Graduate or GED completed

Some college credit, but no degree

Associate Degree

Bachelor\'s Degree

Master\'s Degree

Doctorate or Professional Degree

Unknown

Ancestry

Was Deceased of Hispanic Origin?

No, not Spanish/Hispanic/Latino

Yes, Mexican/Mexican America/Latino

Yes, Puerto Rican

Yes, Cuban

Yes, Central American

Yes, South American

Yes, Other

Unknown

Hispanic Origin: Other

Occupation

Type of Industry

Was the Deceased Ever in U.S. Armed Forces?

Yes

No

Informant's First Name

Informant's Last Name

Informant's Address

Relationship to Deceased

Phone Number of Responsible Party

Alternate Phone Number

Email of Responsible Party

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Why Cremation Center of Kansas City?
Cremation Information
Obituaries
Pets
Contact

Cremation Center of Kansas City

Phone: (913) 384-5566 | Fax: (913) 384-5567

info@cremationcenterkc.com

4926 Johnson Drive

Roeland Park, KS 66205

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General Price List

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