Brooks Cremation and Funeral Service - Ft. Lauderdale, Miami, Palm Beach

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arrangement / vital statistic form

The following information is needed to complete the State of Florida "Death Certificate." ALL QUESTIONS MUST BE ANSWERED. If any answer is not known, simply fill in or select "UNKNOWN" from the drop down menu.

A Birth Certificate, Passport or military discharge (DD 214) form may be helpful in completing the form.

Should you have any questions regarding this form and information requested, please feel free to contact us at (954) 525-5405 for further explanation. This is a secure page

Information about the person completing this form:
First Name
Middle Name
Last Name
Street (do not use PO Box)
City, State, Zip
Phone 1
Phone 2
Fax
E-Mail
I am planning for:

Information about the person you are planning for:
1. First Name
2. Middle Name
3. Last Name
4. Street (do not use PO Box)
5. City, State, Zip
6. County of Residence
7. Gender
8. Social Security Number	- -
9. Date of Birth (mm/dd/yyyy)	/ /
10. Military Service?
11. Place of Birth (city, state, country)
12. Occupation (primary throughout lifespan, DO NOT USE RETIRED)
13. Type of Industry (as it relates to #11 above)
14a. Marital Status?
14. Surviving Spouse (if wife, give MAIDEN name)
15. Hispanic or Haitian origin?
16. Race
17. Highest grade of formal education
18. Father's Name (first, middle, last)
19. Mother's Name (first, middle, MAIDEN)
20. This person is currently...
21. If other...

Additionally, the person listed below may be contacted, should additional information be needed at the time of death:
Name
Address (do not use PO Box)
City, State, Zip
Phone
E-mail
Relationship to above person:

Wishes & Payment Information:
What are your wishes for the cremated remains? (ashes)
If other...
Preferred Payment Method:

Other / Comments:

Upon our review, a representative will contact you by telephone to complete the arrangement. All original documents will be presented to you for signature and final review. At that time you will enclose payment with the signed documents.