McCafferty Funeral & Cremation Inc.
This form is used to obtain information needed for the death certificate and funeral arrangements.
* Required
Email address
*
Your email
Name of Deceased
*
Your answer
Decedent's Address
Your answer
Age
Your answer
Approximate Height and Weight of Deceased
Your answer
Sex
Male
Female
Date of Birth
MM
/
DD
/
YYYY
City of Birth
Your answer
County of Birth
Your answer
Country of Birth
Your answer
Date of Death
MM
/
DD
/
YYYY
Place of Death (Name or Address)
Your answer
Race
Choose
White
Black/African american
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Asian
Native Hawaiian
Samoan
Unknown
Decedent of Hispanic Origin
Choose
No, Not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Social Security #
Your answer
Education Level
Choose
8th Grade or Less
No Diploma, 9th-12th grade
High school graduate or GED Completed
Some college credit, but no degree
Bachelor's degree
Master's degree
Doctorate
Occupation
Your answer
Industry
Your answer
Father's Name
Your answer
Mother's First Name and Maiden Name
Your answer
Veteran
Yes
No
If Veteran, Branch of Service
Your answer
Marital Status
Choose
Married
Widowed
Divorced
Never Married
Unknown
(If Married) Husband's Name / Wife's First Name and Maiden Name
Your answer
Next of Kin's Full Name
Your answer
Next of Kin's Address
Your answer
Relationship
Your answer
Next of Kin's Phone #
Your answer
By checking below I understand that the information in this form is correct and that this information will be used on the death certificate and all necessary documents pertaining to the funeral arrangements for the person listed above.
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