Vital Statistics Form

4926 Johnson Dr.,
Shawnee Mission, KS 66205
Office Hours: Monday-Friday 9-5
Available by phone 24/7
913-384-5566

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.

Informant's Information

First Name *
Last Name *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
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.