Vital Statistics Information Form | William Gayleano Murray & Son Funeral Home, Inc.

Vital Statistics Information Form

(Cremation Death Certificate)

Prefix ( Please Select)

First Name

Middle Name or Middle InitialType NA for None

Last Name

Maiden Name/ Last Name at Birth

Generational ID

Sex

MaleFemale

Social Security Number

Place of Death( If Advance Planning Leave Blank)

Date of Death( If Advance Planning Leave Blank)

Date Of Birth

Age

State of Birth( U= Unknown )

City of Birth( U= Unknown )

County of Birth ( U= Unknown )

Country of Birth( Answer Only If Not United States )

Decedent's Address

Street

City

State/Province

ZIP/Postcode

County

Inside City Limits

YesNoUnknown

Was Decedent in Military of Armed Forces ?

YesNoUnknown

Decedent's Last Occupation( U= Unknown) ( D= Disabled)

Kind of Business or Industry( U= Unknown) (N= None)

Last Employer( U= Unknown) (N= None)

Marital Status

Spouse NameFirst, Middle Name or Middle Initial, Last ( If Wife, Give Maiden Name) ( N=None)

Decedent's Fathers NameFirst, Middle Name or Middle Initial, Last ( N=None)

Decedent's Mothers NameFirst, Middle Name or Middle Initial, Last Name should be Maiden Name ( N=None)

Decedent's Mothers Name at Birth ( Maiden Name)

Decedent's Highest Level of Education

Legal Next of Kin ( First, Middle Name of Initial, Last Name, Address)

Street

City

State/Province

ZIP/Postcode

Hispanic Origin

(Specify Below)

Decedent's Race

Specify Race from above if needed

Method of Disposition

Cremation

Contact information for person completing this form

Name

Relationship to Deceased

Street

City

State/Province

ZIP/Postcode

Telephone

Email Address

Please contact us at 404-963-5634 after completing this form to schedule arrangements.

CERTIFICATION AND INDEMNIFICATION

THE AUTHORIZING AGENT ACKNOWLEDGES THAT WILLIAM GAYLEANO MURRAY & SON FUNERAL HOME, INC. IS RELYING UPON THE REPRESENTATIONS BEING MADE BY THE AUTHORIZING AGENT IN THIS AUTHORIZATION. THE AUTHORIZINGAGENT CERTIFIES THAT ALL OF THE INFORMATION AND STATEMENTS CONTAINED IN THE AUTHORIZATION ARE ACCURATE AND NO OMISSIONS OF ANY MATERIAL FACT HAVE BEEN MADE. THE AUTHORIZING AGENT AGREES TO INDEMNIFY AND HOLD HARMLESS WILLIAM GAYLEANO MURRAY & son funeral home, inc., THEIR OFFICERS, DIRECTORS, EMPLOYEES AND AGENTS FROM ANY AND ALL CLAIMS, DEMANDS, ACTIONS, CAUSES OF ACTION OR SUITS OF ANY KIND OR NATURE WHATSOEVER, INCLUDING, BUT NOT LIMITED TO, LEGAL FEES ARISING OUT OF OR RESULTING FROM WILLIAM GAYLEANO MURRAY & SON FUNERAL HOME, INC. RELIANCE ON OR PERFORMANCE CONSISTENT WITH THE DIRECTIONS, STATEMENTS, REPRESENTATIVES, AND AGREEMENTS CONTAINED IN THIS AUTHORIZATION AND CREMATION PROCESS DISCLOSURE.

ALL FORMS MUST BE COMPLETED, SIGNED, AND RETURNED TO WILLIAM GAYLEANO MURRAY &SON FUNERAL HOME, INC. IN ORDER FOR CREMATION TO TAKE PLACE. WE’VE MADE THESE FORMS AVAILABLE ONLINE/ BY EMAIL, SO YOU CAN COMPLETE THEM AT YOUR CONVENIENCE IN THE COMFORT OF YOUR OWN HOME. IF YOU HAVE QUESTIONS REGARDING ANY OF THE FORMS ON THIS PAGE, PLEASE CALL OR CONTACT US.

IF THE FAMILYIS UNABLE TO PROVIDE THESE ITEMS, AND CREMATION IS DELAYED BEYOND 48 HOURS, SUCH FAILURE WILL RESULT IN A SHELTERING REMAINS CHARGE OF $75.00 PER DAY.

BY SUBMITTING THIS FORM I AFFIRM I HAVE READ, AGREE TO AND ACCEPT THE TERMS, CONDITIONS, DISCLOSURES, AUTHORIZATIONS AND ACKNOWLEDGEMENTS PRESENTED ABOVE.

Cities Served for $1,275.00 Simply Cremate Package: Cities listed in distance closest to farthest from William Gayleano Murray & Son Funeral Home, Inc. Lithonia, Redan, Stone Mountain, Snellville, Conyers, Decatur, Pine Lake, Lilburn, Clarkston, Avondale Estates, Scottdale, Tucker, Ellenwood, Atlanta, Norcross, Lawrenceville, Grayson, Loganville, Oxford, Stockbridge, Conley, Rex, Porterdale, Duluth, Morrow, Peachtree Corners, Covington, North Metro, Forest Park, Jersey, Mcdonough, Jonesboro, Dacula, Alpharetta, Riverdale, Suwanee, Bethlehem, Roswell, Monroe, SocialCircle, Lovejoy, Red Oak, Auburn, Smyrna, Marietta, Buford, Hampton, Mansfield, Mableton, Locust Grove, Union City, Austell, Fayetteville, Winder, Jenkinsburg, Sunny Side, Canton, Rutledge, Good Hope, Jackson, Hoschton, Fairburn, FloweryBranch, Lithia Springs, Newborn, Cumming, Braselton, Clarkdale, Griffin, Woodstock, Statham, Chestnut Mountain, Tyrone, Bostwick, High Shoals, Experiment, ShadyDale, Kennesaw, Bogart, Bishop, Powder Springs, Oakwood, Flovilla, PeachtreeCity, Lebanon, Douglasville, Holly Springs, Palmetto, Talmo, Watkinsville, Farmington, Gainesville, Jefferson, Monticello, Orchard Hill, Madison, Brooks, Pendergrass,Sharpsburg, Hiram, Acworth, Athens, Newnan, Turin, Milner, Senoia, Winston, BallGround, Williamson, Haralson, Dallas, Buckhead, Gillsville, Nicholson, Zebulon

(Cremation Death Certificate)

Contact information for person completing this form

CERTIFICATION AND INDEMNIFICATION

OUR LOCATION: