NORTH CAROLINA DEATH CERTIFICATE

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North Carolina Death Certificate

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North Carolina Death Certificate

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Personal Information

First, Middle and Last Name of Deceased

Suffix (Sr., Jr. III, etc.)

Last Name Prior to FIRST Marriage (Maiden Name), if applicable

Sex

Social Security Number

Date of Birth

Age

Birthplace (COUNTY and State)

Date of Death

Did Decedent Serve in US Armed Forces?

Branch of Military (Leave blank if NA)

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Decedent's Residence/Place of Death/Family Information

Decedent's Full Address

County of Residence

Is Residence in City Limits?

Yes

Unknown

Place of Death (Choose One)

Facility Name (If death did not occur in a facility, provide street address)

Marital Status

Surviving Spouse's Full Name (If Widowed/Divorced, Leave Blank)

Father's Full Name (If unknown, write unknown)

Mother's Full Name (Include Maiden Name. If unknown, write unknown)

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Informant Information (Person Legally Responsible for Disposition)

Informant's Name

Informant's Relationship to Deceased

Informant's Full Address (City, State, Zip Code)

Informant's Telephone #

Informant's Email Address

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Final Disposition

Method of Disposition

Name of Cemetery (Include City and State). If cremation, leave blank

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Decedent Attributes

Decedent's Usual Occupation (DO NOT PUT RETIRED. Instead, use last job worked)

Kind of Business/Industry (Education, Healthcare, Law Enforcement, Private, etc.)

Decedent's Highest Level of Education

Is Decedent of Hispanic Origin?

Decedent's Race

NORTH CAROLINA DEATH CERTIFICATE

North Carolina Death Certificate

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