Boise Funeral Home ~ Aclesa Chapel by tyl42823

VIEWS: 0 PAGES: 3

									                     Boise Funeral Home ~ Aclesa Chapel
                            8209 Fairview Avenue                  Boise, Idaho 83704
                Phone: 208-322-2998 or 208-322-3999      Fax: 208-658-7042      Email: dembo64@aol.com

This information is used to complete the death certificate. If you don't know the answer to a question write "unknown"
and that is what will appear on the certificate. Please print clearly.



Decedents Legal Name:
__________________________________________________________________________________________________
        First                           Middle                       Last                               AKA or Suffix
Sex: _____male ______female
Social Security Number:_________-__________-________
Current Age:______
Date of Birth: (xx/xx/xxxx)_________________________________________________________________________
Birthplace: (City and State)_________________________________________________________________________
Residence Information:
        State:______________________
        County:____________________
        City:_______________________
        Street Address (no po boxes):_________________________________________________
        Apt #_______________
        Zip Code:____________________
        Inside City Limits? _______yes _______no
Marital status at time of death? _______married __________married but separated _______widowed
                                 _______divorced _________never married _________unknown
Surviving spouse's name (If wife give MAIDEN name):
_________________________________________________________________________________________________
        First                           Middle                           Last (Maiden)
Was the deceased ever in the Armed Forces? _________yes          BRANCH_____________
                                                 _________No
The decedent's father's name:_______________________________________________________________________
                                First                           Middle                           Last
Fathers state of birth:____________________________
The decedent's mother's MAIDEN name:______________________________________________________________
                                        First               Middle             Last (Maiden)

Mother's state of birth:___________________________
Informants Name:(Person in charge of arrangements)
___________________________________________________________________________________________
  First          Middle                     Last                                        Relationship to decedent


Informants mailing
address:__________________________________________________________________________
                         Number and Street                  City         State                                    Zip Code
Informants phone number:_______________________________________
Method of disposition: ___donation ____cremation ____entombment ____burial ___removal from Idaho _______other
Name of Cemetery: _______________________________________
Decedent's Usual Occupation
(example: accountant, do not list retired):________________________________________________________________
Kind of Business/Industry:___________________________________________________________________________
Decedent's Education (check the line that best describes the highest degree or level of school completed at time of death):
          ____8th grade or less (includes none)     _____9th - 12th grade, but no diploma
          ____High School Graduate or GED           _____Some college credit but no degree
          ____Associates Degree (e.g., AA,AS)       _____Bachelors Degree (e.g., AB,BA,BS)
          ____Master's Degree                       _____Doctorate or Professional Degree
Decedent of Hispanic Origin? Check one or more boxes to best describe whether the decedent is
      Spanish/Hispanic/Latino. Check the no box if decedent is not Spanish/Hispanic/Latino
          ____No
          ____Yes, Mexican, Mexican American, Chicano
          ____Yes, Puerto Rico
          ____Yes, Cuban
          ____Yes, other Spanish/Hispanic/Latino_________________(Specify)
Decedent's Race:
          ____White                ____Black or African American               ____Asian Indian
          ____Chinese              ____Filipino                                ____Japanese
          ____Korean               ____Vietnamese                              ____Other Asian (Specify):______________
          ____Native Hawaiian      ____Guamanian or Chamorro                   ____Samoan
          ____American Indian or Alaska Native (name of the enrolled or principal tribe):__________________________
          ____Other Pacific Islander (specify):_____________________
          ____Other (specify):__________________________________
How many certified death certificates are needed?:_______at $13 each
Free Veteran Copy?:______(Veterans Only)
Death Notice For:_____Statesman(charges apply to publish service info)_____Press Tribune ($25.00)
Obituary for What Paper?(prepaid and email only)_______________________________________________________
Additional Information/Contact Information/Service Information/Special Requests:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

								
To top