Vital Statistics | Potter Funeral Home

If A Death Has Just Occurred

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PERSONAL INFORMATION OF THE DECEASED

First Name*

Middle Name

Last Name*

Date of Birth*

Date of Death*

Time of Death

Social Security Number*

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PREPARATION INFORMATION

Has a Doctor / Coroner Been Notified?

Do you permit us to embalm the body?

Has the Body Been Released for Removal?

Do You Permit Us to Cremate the Body?

If Yes, Who Has Granted Permission?

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PHYSICIAN INFORMATION

Name of Doctor Signing Death Certificate*

Email Address

Business Telephone

Street Address

City

State

Zip Code

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PERSONAL INFORMATION OF PERSON LEGALLY RESPONSIBLE FOR DISPOSITION

First Name*

Middle Name

Last Name*

Relationship to Deceased*

Street Address

City

State

Zip Code

Primary Phone Number*

Secondary Phone Number

Best Time to Reach Via Phone

Do you have arrangements on file with us?

If Yes, Under What Name?