VITAL STATISTICS INFORMATION Email NAME Gender MaleFemale Birthdate Birthplace (including county) ADDRESS Street Township Boro/City State or Country County Zip Code Veteran?YesNo Martial Status —Please choose an option—MarriedWidowedDivorcedNever Married Spouse (Including Maiden Name) Father's Name Mother's Name (Including Maiden Name) Race Occupation Education 8TH GRADE OR LESSNO DIPLOMA (9TH—12TH GRADE)HIGH SCHOOL OR GEDSOME COLLEGE CREDITASSOCIATE DEGREEBACHELOR’S DEGREEMASTER’S DEGREEDOCTORATE INFORMANT Name Relationship Informant Mailing Address Informant Phone Number Current Location —Please choose an option—Hospital: INPATIENT Hospital: ER/OUTPATIENTHospiceNursing HomeResidenceOther Facility Name (if appropriate) Facility Address County Cemetery Name Cemetery Address BurialCremationRemoval from StateDonation Δ