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Required fields are marked with an "*". If you do not know the answer to a field, please enter "unknown" or "n/a".
Death Certificate Worksheet
* Member's Name (First, Middle, Last)
Maiden Name
* Sex
Male Female
Social Security Number
Age-Last Birthday(Years)
* Date of Birth
Birth Place (City and State or Foreign Country)
Other:
Nursing Home
Residence
Other (Specify)
Marital Status
Never Married
Married
Widowed
Divorced
Unknown
Surviving Spouse (If wife, give maiden name)
* Would you like to sign-up your spouse as well?
Yes No
Decedent's Usual Occupation (Give kind of work done during most of working life. Do not use retired.)
Kind of Business/Industry
* Was Decedent Ever in U.S. ARMED FORCES?
Yes No Unknown
Residence-State
City, Town, or Location
Street and Number
Inside City Limits or Settled Community?
Yes No Unknown
Zip Code
Was Decedent of Hispanic Origin? (Specify No or Yes-If Yes specify Cuban, Mexican, Puerto Rican, etc.)
No Yes Specify:
Race-Filipino, Black, Alaska Native, White, etc.
White
Black or African American
American Indian or Alaska Native (Name of the enrolled or principal tribe)
Asian Indian
Chinese
Filipin
Japanese
Korean
Vietnamese
Other Asian(Specify)
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify)
Other (specify)
Decedents Education (Specify only highest grade completed)
Elementary/Secondary (0-12)
College (1-4 or 5+)
Father's Name (First, Middle, Last)
Mother's Name (First, Middle, Last)
* Informant's Name (First, Middle, Last)
* Informant's Phone Number
* Informant's Email
* Address
Address 2
* City
* State/Province
* Zip/Postal Code
* Relationship to Decedent
Method of Disposition
Burial
Cremation
Removal from State
Donation
Other Specify
Place of Disposition (Name of cemetery, crematory, or other place)
Location-City, Town, State
I understand the above information will appear on the Certificate of Death that is filed with the State of Alaska Bureau of Vital Statistics. I have read this information and confirm it is correct. I understand there is a charge for any corrections or changes made to the death certificate after it has been filed with the Bureau of Vital Statistics. I also understand this charge will be the responsibility of the person requesting the change.
* Signature
Date

Relationship to the member
your total
$25.00
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