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Deceased Information

Please complete all questions below. If you have any questions, please do not hesitate to call us - (919) 496-3161

Informant Information

First Name * You must enter a valid first name

Middle Name You must enter a valid middle name

Last Name * You must enter a valid last name

Street Address * You must enter a valid street address

City * You must enter a valid city

State * You must enter a valid State

Zip Code * You must enter a Zip Code

Email Address * You must enter a valid email address

Phone * You must enter a valid phone number

Relationship * You must enter a relation

Deceased Name

First Name * You must enter a valid first name

Middle Name You must enter a valid middle name

Last Name * You must enter a valid last name

Deceased's Residence

Street Address

City

State

Zip Code

Deceased's Personal Information

SSN * You must enter a valid SSN

Gender

Date of Birth

You must enter a valid date of birth.

Birth City You must enter a valid city

Birth State You must enter a valid State

Race

Marital Status You must select a status

Additional Information

Education Level

Military Service

Occupation

Type of Business/Industry

Years in Industry

Additional Survivors (Names & Relationships)

Spouse Information

First Name

Last Name

Maiden Name

Mother's Information

First Name

Middle Name

Last Name

Maiden Name

Birth State

Father's Information

First Name

Middle Name

Last Name

Birth State

Comments/Special Instructions