Illinois Cremation Centers - Home

Vital Statistics Information

Please fill out the form below.

Name of Deceased - First Middle Last Suffix:

Gender:

Date of Death:

Date of Birth:

Place of Death:

Facility Name:

Address:

Apt#:

City:

Zip:

Country of Birth:

State of Birth:

City of Birth:

Social Security Number of Deceased:

Marital/Civil Union Status:

Surviving Spouse/ Civil Union Partner:

Armed Forces:

Deceased Residence Country:

State:

County:

City:

Street Address:

Apt#:

Zip:

Inside City Limits:

Father's Name:

Mother's Name:

Informant's Name:

Informant's Relationship to Deceased:

Informant's Address:

Informant's City:

Informant's State:

Informant's Zip:

Education:

Was the deceased of Hispanic Origin:

Race:

Usual Ocupation:

Type of Industry: