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
 
Veteran’s 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 Spouse’s name
(if wife, please give maiden name):
 
Professional Information
Usual Occupation
(if retired, give former occupation):
Kind of Business or Industry:
 
Father's Information
Father’s Full Name:
Father’s place of birth
(give state or country):
 
Mother's Information
Mother’s Full Name
(give maiden name):
Mother’s 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
 
 

top | home

 
   

© Costello Funeral Home