Serving all of CT · 860.357.4622

Vital Statistics for Death Certificate

Vital Statistics Form

To prepare a death certificate

Please complete each box in the form below as accurately as possible. You can also download a copy of the form here and email it to luddycremationcare@gmail.com.

Deceased's Name*
First Last
Age*
Date of Death
MM slash DD slash YYYY
Hour of Death
: Hours
Minutes
AM/PM
Deceased's Address*
Street Address City State ZIP Code
County
Place of Death*
Street Address City State ZIP Code
County
Sex*
- Male
- Female
Race - Ethnicity*
Marital Status*
Citizen*
Birthplace*
Date of Birth*
MM slash DD slash YYYY
Father's Name
First Last
Mother's First & Maiden
First Last
Surviving Spouse (If wife, give Maiden Name)
First Last
Occupation*
Employer*
Highest Education*
Social Security No.
If Veteran, Name War & Branch of Service
Rank and Service No.
Informant's Name*
First Last
Informant's Email*
Informant's Telephone*
Informant's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Information

Additional Required Forms
You MUST fill out all 3 forms in order to complete the process.
CT Cremation Permit Crematory Authorization

Luddy Cremation Care
860.357.4622 · luddycremationcare@gmail.com
205 South Main Street, New Britain, CT 06051

Vital Statistics for Death Certificate

Vital Statistics Form

To prepare a death certificate

Additional Required Forms

Luddy Cremation Care