Suburban Funeral Service

Information Form For Death Certificate

SFS Info Form

Decedent's Full Name(Required)

Decedent's Full Address (Street, City, State & Zip code, include county of residence)(Required)

Place of Death (name & address of facility, if applicable)(Required)

Date of Death(Required)

Date of Birth(Required)

Age(Required)

Place of Birth (City or Town & State or Country)(Required)

Social Security Number(Required)

Ex. 123-45-6789

Veteran(Required)

Yes

Ethnicity/Race (if Hispanic, please give origin e.g. Cuban, Puerto Rican, Dominican, etc.)(Required)

Post Title

Gender(Required)

Marital Status – Check One(Required)

Never Married

Married

Divorced

Widowed

Separated

Estimated weight in pounds(Required)

Name of Spouse (for wife, include birth name, prior to marriage)(Required)

Father's first and last name(Required)

Mother's birth name (please do not enter married name)(Required)

Education Level (list grade completed, HS Diploma or select College degree, BA, MA, PhD, etc. if applicable)(Required)

Usual Occupation During Lifetime (Please Do NOT list Retired)(Required)

Type of Industry or Business of Occupation(Required)

Burial or Cremation (if burial, please provide name of Cemetery & plot location)(Required)

Untitled

Number of death certificates requested ($10 each NYS & $15 each NYC)(Required)

Name of Informant & relationship (person authorizing burial or cremation)(Required)

Informants full address (Street, City/Town, State & Zip code)(Required)

Informants Email(Required)

Enter Email Confirm Email

Informant phone number (Include area code)(Required)

Please attach a recent photo of the deceased.(Required)

Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 8 MB.

Please attach a picture ID of the next of kin (signor).(Required)

Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 8 MB.

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WE ARE AVAILABLE 24 HOURS A DAY

Servicing all of the Bronx, Westchester, Putnam, Dutchess, Orange, And Ulster Counties And Beyond

SUBURBAN FUNERAL SERVICE

414 Washington Street, Peekskill, New York 10566 United States

Office Telephone (914) 530-3600

Office Telephone (845)-459-3355

Office Fax (914) 206-9615