4926 Johnson Dr., Shawnee Mission, KS 66205
Office Hours: Monday-Friday 8-4
Available by phone 24/7
913-384-5566

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Vital Statistics Form

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

If you are human, leave this field blank.

Deceased's Information

First Name *

Middle Name or Inital

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

If residence, please include address

Date of Birth *

mm/dd/yyyy

City of Birth *

State of Birth *

Social Security Number

Marital Status at Time of Death *

Married

Widowed

Divorced

Never Married

Married, but Seperated

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 *

English, Irish, French, German, etc.

Was Deceased of Hispanic Origin? *

No, not Spanish/Hispanic/Latino

Yes, Mexican/Mexican America/Latino

Yes, Puerto Rican

Yes, Cuban

Yes, Centeral American

Yes, South American

Yes, Other

Unknown

Be specific

Hispanic Origin: Other

Occupation *

Primary occupation during working years. *Do not enter \"retired\".

Type of Industry *

Sales, Medical, Engineering, Construction, etc.

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

Yes

Company(s) worked for, years worked, special recognition, retirement date

Surviving Family Members

Please list survivors and relationship: son, daughter, brother, sister, etc.

Memberships and Activities

Religious affiliations, fraternal and civic organizations, hobbies, etc.

Informant's Information

First Name *

Last Name *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Relationship to Deceased *

Phone Number of Responsible Party *

Alternate Phone Number

Email of Responsible Party *

A copy of what is submitted will be sent to this email.

Captcha *

reCAPTCHA is required.

$1195

Direct Cremation

$995

Direct Cremation Online Only

Obituaries & Condolences

Patricia Anne Pierce

Thomas Fred Wing

William Raymond Wood

Patricia Jewell

Susan “Susie” Elaine Buterbaugh

Scott Lee Scribner

Claude Fredrick Bumpus Sr.

Michael Norman White

Allene M. Gantz

Glen W. Payne

Joseph “Joe” Mahlon Chase

Joseph ‘Bernard’ Loftus

View All Obituaries & Condolences

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Obituaries & Condolences

Patricia Anne Pierce

Thomas Fred Wing

William Raymond Wood

Patricia Jewell

Susan “Susie” Elaine Buterbaugh

Scott Lee Scribner

Claude Fredrick Bumpus Sr.

Michael Norman White

Allene M. Gantz

Glen W. Payne

Joseph “Joe” Mahlon Chase

Joseph ‘Bernard’ Loftus

4926 Johnson Dr.,
Shawnee Mission, KS 66205
Office Hours: Monday-Friday 9-5
Available by phone 24/7

913-384-5566
info@cremationcenterkc.com

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