Matthews Mortuary Funeral Record Form

Please fill out our Funeral Record form which is necessary for a Death Certificate.

Deceased's Full Name:
Deceased's Date and Time of Death:
Deceased's Place of Death:
Deceased's Age:
Deceased's Physical Address:
Within City Limits? Yes   No
Deceased's Birth Date and Birth Place:
Deceased's Social Security Number: Please call with info.
Ever Served in the Armed Services? Yes   No
Name of Doctor:
Father's Full Name:
Father's Birth Place:
Mother's Full and Maiden Name:
Mother's Birth Place:
Marriage Status: Married   Single   Widowed   Divorced
Surviving Spouse:
Place and Date of Marriage:
Year's of Education:
Deceased's Occupation:
Informants (Names and Relationships):
Informants' Addresses:
Informants' Phone Numbers: 
Place/Date/Time of Funeral:
Place/Date/Time of Viewing: