(716) 674-5776 Fax (716) 674-5908
www.curtinfuneralhome.com
Arrangement Information
This is the information that we will need for the
for NY Death Certificate
Please print out this simple form and complete before coming to the funeral home
Vital Statistics
Correct Name
___________________________________________
(First, Middle Name or
Initial, Last)
Maiden Name
_______________________________
Nickname _______________________________
Residence of Deceased:
Street &
Number- __________________________
Locality - Check one
and Specify: £City £Village
£Town
Locality
Name -
State______________ Zip Code-
_______________ Sex
- £ Female £
Male
Date of
Birth______________________ City of
State of
Served in US
Armed Forces? - £ No £ Yes Branch of
service?_______________
Years in service? (e.g. 1943-1945)________________________________
Will you want a
military service? £ No £ Yes
We will need military
discharge papers/ DD214
Race - (White, Black, etc.)________________ Of Any Hispanic
Origin? £ Yes £ No -
If Hispanic,
specify _______________ Highest
Education- specify only highest grade completed ______________
Social Security No. ___ ___ ___-___ ___-___ ___
___ ___
Usual
Occupation during working years, before retired
(e.g. Housewife, Millwright,
Carpenter, Painter Doctor)
_____________________________________________
Kind of
Business ________________________________
Name of
Business _______________________________
City &
State of Business __________________________
Father’s
Name
______________________________________________
(First, Middle Name or
Initial, Last)
Mother’s
Name
______________________________________ Mother’s Maiden
Name___________________
(First,
Middle Name or Initial, Last)
Martial Status-
£ Never
Married £Married
£ Separated £
Widowed £Divorced
Spouse’s
First Name ______________________________ Spouse’s
Middle Initial ______
Spouse’s
Last (Maiden) Name_______________________
Disposition
Type of Disposition:
£ Traditional
Funeral Service
£ Traditional
Cremation Service
£ Direct
Cremation
£ Graveside
Burial Service
£ Direct
Burial
£ Memorial
Cremation Service
£ Graveside
Cremation Service
£ Other – something else to fit my needs
Cemetery Information
(city &
state)
Grave Location in Cemetery_________________________
Is there a
monument/marker on the plot £ Yes £ No
Funeral
Service to be held at
£ Church
___________________________________
£ Curtin
Funeral Home
£ Graveside
Service
£ No Service
£ Memorial
Cremation Service
£ Graveside
Cremation Service
£ Other
_______________________________
Membership
in Organizations
£ Church
Organizations ________________________
£ V. F. W.
__________________________________
£ American
Legion___________________________
£ Fire Company
______________________________
£ Masons
___________________________________
£ Shrine ___________________________________
£ K of C ___________________________________
£ Knight of
£ Other ____________________________________
Information
about Person completing this form
Name________________________________________________
Address
(street)_________________________________________
City_________________________
State_______ Zip___________
Your Relationship
To Person Above- This is my: ________________
E-Mail
Address_________________________________________
Daytime
Phone Number (____)_______-________________
Evening Phone Number (____)________-_______________