Personal Information Form

McCombs Funeral Home, Inc - Personal Information Submission Form
Decedent's Legal Name - First, Middle, Last, Suffix: (Please include A.K.A's if any)*
Sex*

MaleFemale
If Female, Last Name Prior to Marriage*
Date/Time of Death*

MonthDayYear
Age*
Date/Time of Birth*

MonthDayYear
Birth Place: City*
Birth Place: State*
Birth Place: Country*
Social Security Number*
Decedent Served In U.S.Armed Forces*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County*
Inside City Limits?*

YesNo
Marital Status At Time Of Death*

MarriedDivorcedMarried, but separatedNever MarriedWidowedUnknown
Surviving Spouse's Name (If wife, give name prior to first marriage)*
Father's Name (First, Middle, Last, Suffix)
Mother's name prior to first marriage (First, Middle, Last, Suffix)*
Contact Person's Name*
Contact Person's Relationship*
Contact's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact's Phone Number*

Area CodePhone Number
County Of Death*
Did Death Occur In Hospital*

YesNo
If so:*

InpatientEmergency RoomDOA
If Death Occured Somewhere Other Than Hospital:*

Hospice FacilityNursing HomeDecedent's HomeOther
If OTHER, please specify
Facility Name*
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Facility Phone*

Area CodePhone Number
Decedent's Highest Level of Education*

8th Grade or Less9th-12th Grade, No DiplomaHigh School or GEDSome College Credit, No DegreeAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate Degree
Decedent's Race*
Decedent's Origin*

HispanicLatinoSpanishMexicanMexican AmericanChicanoPuerto RicanCubanNone of the above
If Decedent is Retired, List Most Recent Occupation*
Decedent's Occupation, be specific, list job title and company*
Attach Decedent's Photo

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McCombs Funeral Home, Inc - Personal Information Submission Form