The following information is necessary to provide to the Commonwealth of Massachusetts Registry of Vital Records and Statistics for death certificate purposes. It is helpful to have this information on record in the event of a death. We have also included space to record your Funeral Service preferences.

 
Individual's Information

Name:
Residence address:
 
Next of Kin

Next of Kin
(spouse or closest living blood relative):
Residence Address:
Relationship:
Phone
xxx-xxx-xxxx:
Email
 
Veteranís Information

War:
Branch of Service:
Service Number:
Rank/Rating:
Date of Entry into Military:
Date of Discharge:
Location of Discharge papers:
 
Education

Please list highest number of years of education completed
(0-12 or College: 1-5+):
 
Birth Information

Date of Birth:
Birthplace
(List City and State OR Country):
 
Marital Information

Marital Status:
Last Spouseís name
(if wife, please give maiden name):
 
Professional Information

Usual Occupation
(if retired, give former occupation):
Kind of Business or Industry:
 
Father's Information

Fatherís Full Name:
Fatherís place of birth
(give state or country):
 
Mother's Information

Motherís Full Name
(give maiden name):
Motherís place of birth
(give state or country):
 
Funeral Service Preferences

Place of Service:
Method of Disposition:
Religious Affiliation:
Place of Worship:
Visitation:
Other Affiliations
(Masons, Knights of Columbus, etc.):
 
Cemetery Information

Cemetery Name:
Cemetery Address:
Location of Cemetery Deed:
Lot information/Section:
 
Special Instructions

Flowers:
Music:
Casket Bearers:
Jewelry, Glasses, Clothing, etc.:
Donations to charity:
Information Request:
 
Submitter's Information

Your Name:
Relationship to individual:
Address:
Phone:


 
This information will be emailed directly to us at CostelloFH@Comcast.net
 
 

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