Biographical Information Form

The following information is needed for the proper filing of a death certificate. A certified death certificate is usually required for various legal or banking purposes. 

We suggest you first review the form, gather the needed information, and then plan on spending 10 to 15 minutes filling everything out. Updating or correcting a death certificate after filing can be time-consuming and you may incur an additional fee, so take your time. This information will be provided to the funeral director.

The Willow package includes certified copies of the death certificate and we can always order more for you if needed. If you have any questions about the form or need assistance, please email us directly, or call us at 877-646-9945.

 
Name *
Name
Residence
Residence
Sex
Date of Birth
Date of Birth
Place of Birth
Place of Birth
Date of Death
Date of Death
Any implanted devices?
A pacemaker for example
Served in U.S Armed Forces?
Name of Surviving Spouse
Name of Surviving Spouse
If wife, please enter maiden name
Please do not enter "retired"
Father's Name
Father's Name
Mother's Name
Mother's Name
Please include maiden name
Informant 1
Informant 1
This person will be listed on the death certificate
Informant 1 Address
Informant 1 Address
Primary Phone Number
Primary Phone Number
Informant 2
Informant 2
Informant 2 Address
Informant 2 Address
Primary Phone Number
Primary Phone Number
Submitter's Name
Submitter's Name