Dennett, Craig & Pate Family Worksheet

Information for Death Certificate

This Family Worksheet includes the information that is required in order for Dennett, Craig & Pate Funeral Home to obtain a Death Certificate. Please complete this form to the best of your knowledge. It would be helpful if this form could be completed before we meet in person. If you have any questions about anything being asked, please feel free to contact us and we will help you with completing the form.

Please Identify Your Preference:
	Please send me information about Pre-Planning
	Please contact me to set an appointment
	No appointment needed at this time. Please keep my information on file.

* Is Required Information

Contact Information
Name*
City*
State*
Zip*
Phone*

Deceased's Name
First Name
Middle Name
Last Name
Suffix

Address of Deceased
Street
City
State
Zip

Statistical Information
Date of Death
Sex
Social Security Number
Age
Date of Birth
Birthplace
Ancestry
Race

Deceased's Military Information

Veteran Yes No

Branch of Service

Is there a copy of a DD214?
(This document verifies military service.)
Yes No

Wars Served In

Other information
Place of Death
Marital Status	Married Never Married Widowed Divorced Domestic Partner
Last Spouse's Name
Is Spouse Living	Yes No
Occupation
Industry
Highest Level of Education

Father's Information
First Name
Middle Name
Last Name
Name Suffix

Mother's information
First Name
Middle Name
Maiden Name

Next of Kin Contact Information
Name
City
State
Zip
Phone

Information for Preparation of Obituary

An Obituary is an important part of the final arrangements for your loved one. If you would like to prepare an Obituary yourself, please either provide us with a hard copy of it or e-mail it to us and we will submit it to all of the appropriate places, as determined in our meeting.

If you would prefer, Dennett, Craig & Pate Funeral Home is happy to assist you with preparing an obituary for your loved one. By completing the form below, we will prepare a draft of an Obituary; we would then ask you and your family to review it and make any changes you see fit in order to ensure that it is an accurate reflection of your loved one's life.

Obituary Family Information

Sons

Daughters

Brothers

Sisters

Number of Grandchildren

Number of Great Grandchildren

Number of Great Great Grandchildren

Other Obituary Information
Education (i.e.) High School, College, course studies/degree(s)
Organizations
Employment
Hobbies
In Lieu of Flowers