Suburban Funeral Service

Information Form For Death Certificate

SFS Info Form

Decedent's Full Name(Required)

Decedent's Address (Street, City, State & Zip code)(Required)

Place of Death (name & address of facility)(Required)

Date of Death(Required)

Date of Birth(Required)

Age(Required)

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

Social Security Number(Required)

Ex. 123-45-6789

Veteran(Required)

Yes

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

Gender(Required)

Marital Status – Check One(Required)

Never Married

Married

Divorced

Widowed

Separated

Estimated weight in pounds(Required)

Name of Spouse (If wife, include maiden name prior to marriage)(Required)

Father's first and last name(Required)

Mother's first and maiden name (please do not enter married name)(Required)

Education (list highest grade completed or highest degree if applicable)(Required)

Usual Occupation (prior to retirement)(Required)

Type of Industry or Business(Required)

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

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

Name of Informant & relationship (person authorizing)(Required)

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

Informant Email(Required)

Enter Email Confirm Email

Informant phone number(Required)

Documentation Required(Required)

Drop files here or

Accepted file types: jpg, png, Max. file size: 8 MB.

Please attach a recent photo of the deceased and a picture ID of the next of kin (signor).

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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

23 Lockwood Avenue

Yonkers, New York 10701 United States

Office Telephone (914) 530-3600

Office Telephone (845)-459-3355

Office Fax (914) 206-9615