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Vital Statistics Form

This information is used to complete the NJ Death Certificate. If the supplied information is incorrect and will have to be corrected after the certificate is filed, it will result in delays and additional expense.

If you would prefer to print and fill this form by hand please click here.

Deceased's Information

Legal Name of Decedent:

Social Security Number:

Date of Death:

Date of Birth:

Age:

Ethnicity:

Birthplace City, State & County:

Current Address

Address:

City:

Country:

State/Province:

Zip/Postal code:

Military Service (Branch & Service Dates):

Must have Military Discharge to perform military service.

Marital Status:

Surviving Spouse (Maiden Name):

Father's Name:

Father Living?:

Mother's Name (Maiden):

Mother Living?:

Informant Name:

Relationship:

Cell Phone:

Email:

Place of Death

Address:

City:

Country:

State/Province:

Zip/Postal code:

Education Level:

Occupation & Last Employer of Deceased:

This section is to be signed once printed by Costantino Primo Funeral Home.

After Submission

Informant signature:

Date:

Directors Initials:

EDRS #:

Please wait

Vital Statistics Form

Vital Statistics

This information is used to complete the NJ Death Certificate. If the supplied information is incorrect and will have to be corrected after the certificate is filed, it will result in delays and additional expense.

If you would prefer to print and fill this form by hand please click here.

Current Address

Must have Military Discharge to perform military service.

Place of Death

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