Death Certificate Information Form

By completing the online forms, you hereby understand that an electronic signature will be considered as a real and legal signature regardless of deviations from your original or hand written format.

You are also stating that you have read our General Price List, Disclaimers and warrantees on merchandise. Signatures are also utilized to engage in contracted goods and services selected.

Payment Terms: Payment in full prior to the actual cremation process is scheduled.

The information on this document is used for the Death Certificate.

NOTE: FLORIDA LAW PROHIBITS INDIVIDUALS FROM OBTAINING A DEATH CERTIFICATE REFLECTING THE CAUSE OF DEATH, UNLESS THEY ARE IN FACT, A DIRECT RELATIVE (FATHER, MOTHER, SON, DAUGHTER, BROTHER OR SISTER) OF THE DECEASED.

ALL OTHER RELATIONSHIPS MUST SUBMIT PROOF, BY WILL OR COURT ORDER THAT THEY ARE QUALIFIED FOR THESE DOCUMENTS.

Name of Deceased (First, Middle, Last) * 🛈

Social Security Number 🛈

Age 🛈

Date of Birth *

Pacemaker * 🛈

Place of Birth (City-State) or Country * 🛈

Date of Death (if Known) 🛈

Facility / Place of Death (Give Address if Home) 🛈

City of Death * 🛈

City Limits? *

County of Death *

Time of Death 🛈

Race *

Hispanic or Hatian Origin *

Autopsy *

Facility Type *

Education (Last Grade Completed) *

U.S. Military *

Decedent's Last Occupation Title. * 🛈

Type of Industry? * 🛈

Marital Status *

Surviving Spouse (First, Middle, Maiden)

Decedent's Fathers Full Name * 🛈

Decedent's Mother (1st-Middle) * 🛈

Decedent's Mother's Maiden * 🛈

Deceased Legal Address * 🛈

Apt #

City * 🛈

City Limits *

County *

State *

Zip *

Death certificates take time to reach legal status. Standard wait time for death certificates is approximately 10 business days (or more). If you wish for us to "Expedite" death certificates, you may request this premium service, for a fee listed on our price list.

EXPEDITED ORDERS ARE DEFINED AS: "AN ORDER THAT IS REQUESTED BY YOU AND/OR OBTAINED BY OUR FIRM WITHIN 10 BUSINESS DAYS FROM THE DATE OF A PAID CONTRACT ON YOUR BEHALF BY SPECIAL REQUEST.

Expedite Order of Death Certificates: * 🛈

Yes, Per Fee on General Price List - Effective Once Filing Is Competed. Includes Priority Mail.

No Rush Needed. I Can Wait for Standard Filing (10 or more business days)

Informants Full Legal Name * 🛈

Phone # * 🛈

Informant's Street Address * 🛈

City *

Zip Code *

State

Informant's Email Address * 🛈

E-Signature Required * 🛈

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Cremation Arrangements (Circle Must Be Selected) * 🛈

By signing this form, I/We agree that the information provided is correct and grant permission to CSBS to utilized it as required to file legal documents and arrange for cremation arrangements. I/We also agree that I/We am/are legal next of kin or of legal authority to complete such forms for cremation arrangements, for the decedent listed above. I/We also assume responsibility for any fees required for corrections. I also acknowledge that I have received and reviewed prices and approve prices as listed on the General Price List (available online, in person, by phone or mail). The death certificate will reflect the information, as is unless otherwise directed prior to filing.