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*

Street Address

Date of Birth*

Date of Death*

Time of Death

Social Security Number*

Place of Death

Race

Gender

Marital Status

Birthplace

Highest Level of Education

Father's Name

Mother's (Maiden) Name

Occupation

Next of Kin

Would you like Burial or Cremation?

Burial

Cremation

Veteran?

Yes

No

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PERSONAL INFORMATION OF PERSON LEGALLY RESPONSIBLE FOR DISPOSITION

First Name*

Middle Name

Last Name*

Email Address

Relationship to Deceased*

Street Address

Race

City

State

If Yes, Under What Name?

Zip Code

Primary Phone Number*

Best Time to Reach Via Phone

Do you have arrangements on file with us?