Moore's Home For Funerals

Statistical Worksheet

NAME:                                                                    AGE:

DATE OF DEATH:                                                DATE OF BIRTH:

SOCIAL SECURITY #:

PLACE OF DEATH (FACILITY NAME OR HOUSE ADDRESS):

COUNTY OF DEATH:

CITY, STATE ZIP OF DEATH:

LAST RESIDENCE:

COUNTY OF RESIDENCE:

CITY, STATE ZIP OF RESIDENCE:

PLACE OF BIRTH (CITY, STATE OR FOREIGN COUNTRY):

VETERAN (YES/NO)     BRANCH:                         DATES:

MARITAL STATUS:                                            EDUCATION LEVEL:

SURVIVNG SPOUSE (MAIDEN NAME IF WIFE):

NAME & ADDRESS OF LAST EMPLOYER:

TYPE OF BUSINESS:

OCCUPATION:

HISPANIC HERITAGE (YES/NO) IF YES, SPECIFY COUNTRY:

FATHER’S NAME:

MOTHER’S MAIDEN NAME:

INFORMANT’S NAME:                                            RELATIONSHIP:

INFORMANT’S ADDRESS:

INFORMANT’S CITY, STATE ZIP:

CEMETERY:

CITY, STATE: