14640 Flint Lee Rd 
   Chantilly Virginia 20151
   Office: 703-263-1683
   Mobile: 571-490-2249 
1. Name Of Deceased
2. Gender
4. Date Of Birth
3. Date Of Death
5. Age
6. Was the deceased ever in the armed forces?
6.5. If yes where applicable?
23. Where was the place of death? (Hospital/Hospice Facility/Home/Other)
21. Name of hospital or place of death
22. Full street address of place of death, including zip code
9. Full street address of decedents residence, including zip code
16. Name of decedents father (if unknown, write unknown)
17. Name of decedents mother (Her birth name or legal name before married)
10. Race: White/Black/Asian/Hispanic/Native American/Indian/Other
10.5. Describe "Other race" for example: Arab,Kurdish,Berber,Punjabi,Trini,Etc
11. Level of education: No education/1-12 Grade/Associates degree/Bachelors degree/Masters degree/PHD, Doctorates degree
12. Citizen of what country
7. Birthplace,City and State or City and Country
14. Martial status at time: Married/Divorced/Seperated/Never Married/Widowed
15. Spouse's Name (If divorced, write Divorced)
8. Social Security Number (if none write None)
13. Last Job or Career, and Type of Industry (Do not write retired DO NOT LEAVE BLANK)
19. Informant's Name (who is filling out this form?)
18. Informant's relationship to deceased
20. Informant's Mailing Address
24. Place of Disposition (Cemetery name and address)
25. Cause of death (for informational purposes only)
26. Doctor Name, Address and Phone Number (please give this information to the best of your ability)
27. Your email address
28. Your phone number
29. Address where death certificate is to be mailed
30. How many copies of the death certificate are needed? (please calculate one for each bank account, mortgage company, life insurance, credit card, embassy, if there is property back home) $12 a copy in VA
31. Certificates are issued to the address provided within about 2 weeks. For Maryland and DC deaths, please allow the certificate turnaround time to be extended to 3-4 weeks (I have read the above statement.)