Death Certificate Information Form

Thank you for taking the time to provide us with the death certificate information. By completing the following information at your own convenience, you should find it easier to provide correct information and have some time to think about the type of services you desire.

The information provided on this form will help Howe-Peterson Funeral Home complete the death certificate and other required documents. In addition, this information will assist the funeral director to better understand your initial wishes. Relaying required statistical information can be time consuming. Our desire is to help expedite the final arrangement conference at the funeral home and make the process a little more comfortable.

Please complete (as much as possible) the information on the form and select Submit Information at the end to send the information to us. You may also print out the form and fax it, or bring it with you to the arrangement conference.

If you'd prefer, a printer-friendly version of this form is also available for you to download and fill out manually. CLICK HERE for further instructions and the download link.

If you have any questions, please contact Howe-Peterson Funeral Home at: 313-561-1500.

NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

Deceased Vital Statistics for Death Certificate
* First Name:
* Last Name:
Middle Name:
Sex:
Race:
Date of Birth:
Place of Birth:	City: State: Country:
Date of Death:
City of Death:
State of Death:
County of Death:
Location of Death:	If other, please indicate address:
Name of the Place of Death:
Education
Usual Occupation (most of life):
Kind of Business:
Company:
Marital Status:
Full Name of Surviving Spouse:
If Wife, Provide Maiden Name:
Residence - Street Address:
City/Town:
Inside City Limits:
County:
State:
Zip Code:
Father's Full Name:
Mother's Full Maiden Name:

Type of Disposition
Disposition Will Be:
If Cremation, indicate preference of disposition of cremated remains:
Name of Cemetery (if applicable):
City:
State:

Preparation and Viewing
Important Note: Viewing of the deceased is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of deceased via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming. Michigan law requires embalming when death was caused by certain infectious diseases, or, with very limited exceptions, when the deceased is not taken to its final destination (such as a cemetery or crematory) within 48 hours.
The Family Preference Regarding Viewing/Embalming Is:
I Authorize Howe-Peterson Funeral HomeTo Embalm:
Name of Authorizing Person:
Relationship To Deceased:

Veteran Information
Was Decendent Ever In the US Armed Forces?:	Yes No (if no, continue to next section)
Branch of Service:
Is A Copy of Discharge Papers Available?	Yes No (if yes, please bring for us to copy):

Informant/Person In Charge Information
* First Name:
* Last Name:
Relationship To Deceased:
* Email Address:
Address:
City:
State:
Zip Code:
Telephone Number:
Cell phone number:

Funeral/Memorial Service Information
Preferred Place of Service:
If Preferred place of service is a Howe-Peterson Chapel, please indicate which one:
Preferred Day of Service:
Preferred Time of Service:
Religious Denomination:

Other Information & Instructions
Please list any other instruction or information you would like us to have:

NOTE: Emails are not reviewed on weekends.

Death Certificate Information Form - Printer-friendly Version

You can download the printer-friendly version of the Death Certificate Information Form to your local computer from the link below. Once downloaded, open the PDF *, and enter your information on the form, then print it out on your printer. You may also print out the form and fax it, or bring it with you to the arrangement conference.

Dearborn Chapel fax:313-561-2363
Taylor Chapel fax:313-291-0919

» CLICK HERE to download the form - choose to, 'Save to Disk,' in the dialog box that appears (download times will vary depending upon connection.)

* NOTE: Adobe Acrobat Reader software is required to view this file - if you don't already have the Reader installed on your computer, it is available for free from Adobe's website - please click the icon at right to be taken to the download page.

22546 Michigan • Dearborn, MI 48124 • 313-561-1500 9800 S. Telegraph • Taylor, MI 48180 • 313-291-0900

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