Firtion Adams Funeral Home

DECEDENT - NAME FIRST MIDDLE LAST

SEX

DATE OF DEATH (Mo., Day, Yr.)

PLACE OF DEATH (City/Town)

COUNTY OF DEATH

HOSPITAL OR OTHER INSTITUTION (If no in either, give street and number)

PLACE OF DEATH (Check only one.)
HOSPITAL
Inpatient ER/Outpatient DOA

OTHER
Nursing Home Residence Other

SOCIAL SECURITY NUMBER

IF US WAR VETERAN
SPECIFY WAR

WAS DECEDENT OF HISPANIC ORIGIN?
(If yes, Specify Puerto Rican, Dominican, Cuban, etc.)

RACE (e.g. White, Black, American Indian, etc.)
(Specify)

DECEDENT'S EDUCATION (Highest Grade Completed)
Elementary Sec (0-12) | College (1-4, 5+)

AGE -
Last Birthday (Yrs.)

UNDER 1 YEAR
MOS. | DAYS

UNDER 1 DAY
MOS. | DAYS

DATE OF BIRTH
(Mo., Day, Yr.)

BIRTHPLACE
(City and State or Foreign Country)

MARRIED, NEVER MARRIED
WIDOWED OR DIVORCED

LAST SPOUSE
(If wife, give maiden name)

USUAL OCCUPATION
(Prior - if Retired)

KIND OF BUSINESS OR INDUSTRY

RESIDENCE - NO. & ST., CITY/TOWN, COUNTY, STATE/COUNTRY

ZIP CODE

FATHER - FULL NAME

STATE OF BIRTH (If not US, name country)

MOTHER - NAME (GIVEN) (MAIDEN)

STATE OF BIRTH (If not US, name country)

INFORMANT'S NAME

MAILING ADDRESS - NO. & ST., CITY/TOWN, STATE, ZIP CODE

RELATIONSHIP

METHOD OF IMMEDIATE DISPOSITION

BURIAL
ENTOMBMENT
DONATION

CREMATION
REMOVAL FROM STATE
OTH. SPEC

PLACE OF DISPOSITION (Name of Cemetery, Crematory or other.)

LOCATION (City/Town, State)

DATE OF DISPOSITION (Mo., Day, Yr.)

Obituary: