Peter P Dohanich Funeral Home, Inc.
Call Us at 800-321-1163

Serving Families Of All Faiths Since 1984

Direct Cremations from $495 & Direct Burials from $995

 

 

 

   

 

Providing Services:

24 hours a day...

7 days a week...

365 days a year

for At-Need.

Business hours for all questions

 

Death Certificate Information


Upon the request of the Funeral Director:

Please Print This Form And Fax To Number Given By Director

 

Date:

Deceased's Name:

Place of Death:

Telephone:

Date of death:

County of Death:

City:

State:

Male or Female:

Race:

Social security Number:

______________________________________________________________________________

Deceased's Address:

Apartment:

City:

State:

Zip Code:

County:

Country:

_______________________________________________________________________________

City of Birth:

State:

Date of Birth:

Age:

Honorable Veteran- YES or NO; If YES- Dates of Service ___/___/___ to ___/___/___

Education Level (Grades 1 through 12):

College ( 1 to 4 years, 5 or more):

Degree (s):

Occupation (prior to retirement if applicable):

Industry:

Father's Full Name:

Mother's Full Maiden Name:

Marital Status:

Spouse's Full Name (Maiden Name if Wife):

_____________________________________________________________________________

Informant's Full Name:

Relationship to Deceased:

Address:

Apartment:

City:

State:

Zip Code:

E-Mail:

Telephone:

Fax:

I have reviewed the above information and to the best of my knowledge the information I've provided is correct. Any errors found will be my responsibility to correct and not the Funeral Home's.

Signature of Informant:_________________________________________________                               Date:___/___/____