Death Certificate Information

The information below is required by the State of Michigan when completing a Death Certificate.

The primary informant (contact person) will be the person listed on the Death Certificate.  Additional family contact information is required when there are multiple individuals with the same relationship to the deceased.  Example: Children, Siblings, etc. 

Death Certificate Info

Field name	Field
Statistical Information
Full Name
Date of Birth	(xx/xx/xxxx)
Sex	Select Male Female
Name at Birth
Current Residence
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Birthplace
City
State
Country
Personal
Education	Highest level completed
Veteran	Select Yes No
Race
Ancestry	example: German, Dutch, American, etc.
Hispanic Origin	Select Yes No
Employer
Years
Usual Occupation	example: Mechanic, Welder, Nurse, etc.
Kind of Business	example: Tool and Die, Medical, Customer Service, etc.
Marital Status	Select Married Never Married Divorced Widowed
Surviving Spouse
Wife's Maiden Name
Father's Name
Mother's Maiden Name
Contact Information
Primary Informant (name)
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Relationship
Second Contact
Informant (name)
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Relationship
Third Contact
Informant (name)
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Relationship
Fourth Contact
Informant (name)
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Relationship
Fifth Contact
Informant (name)
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Relationship
Sixth Contact
Informant (name)
Address	Address, line 1  Address, line 2    City/State/Zip
Phone	(Area code) Exchange - Number ext.
Cell	(Area code) Exchange - Number ext.
Relationship
How would you like us to contact you?
Contact name
	Phone
Phone number	(Area code) Exchange - Number ext.
	E-mail
E-mail address

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