For your convenience, you can either print this page OR download a two-page .PDF file (when printing, click "Print as Image" option for best results) that includes the statistical information plus other arrangement decisions you will have to make. Type or clearly print all information. Carefully review numeric data (dates and social security numbers) because the correction procedure at the Department of Health can easily take ten to twelve weeks and will cause unnecessary and frustrating delays in the estate settlement process.

Your Information

Full Name

Street Address

City/State/Zip code

Telephone number

Your relationship to the deceased

Decedent Information

Full Name

Was the decedent know by any other names?

Place of death

Residence street address

City/State/Zip code

Marital status (never married/married or separated/divorced/widow or widower)

Date of birth

Place of birth (City/state or foreign country)

Father's full name

Mother's full name (include her maiden name)

Social security number

Veteran status (Yes/no?)

If a veteran, dates of service and branch of armed services

Usual occupation (you cannot enter "retired")

Type of industry

Last employer

Highest amount of education (0-8 | 9-12 | C1-4 | C5+)

Authorizing Person Information

Closest Next of Kin

Relationship to Decedent

Street Address

City/State/Zip

Telephone number

Disposition of the Cremated Remains

Certain cremation documents required by New York State ask for the disposition of the cremated remains. Please consider whether you want them returned to you or if you would like us to arrange for them to be scattered at sea.

Death Certificates

How many death certificates would you like us to have prepared for you by the Department of Health? In New York City, each certified copy is $15.00. Families of honorably discharged veterans who die within City limits are entitled to receive three (3) FREE copies of the certificate of death. Proof of discharge status is required.

Outside of the boroughs, death certificate copies are $10.00 each.