Vital Statistics | Shaw - Davis Funeral Homes | Columbus OH funeral home and cremation Columbus OH funeral home and cremation

Please provide the following information in order to assist us in creating the Death Certificate, so that we can get it to the Doctor for a Signature.

Full Name*

Address*

Street

City

State/Province

ZIP/Postcode

Inside City Limits

Home Phone*

Cell Phone

Email Address*

Date of Birth

SSN

City of Birth

Race

State of Birth

Gender

MaleFemale

OccupationDo not use “Retired

Type of Business

Education in Years (1-12)

College (1-4 or 5+)

Degree

First Name of Spouse

Middle Initial

Last/Maiden Name

First Name of Father

Last Name

First Name of Mother

Maiden Name

Next of Kin

Relationship

Street

City

State/Province

ZIP/Postcode

Home Phone*

Cell Phone

Email Address*

VETERANS INFORMATION

Branch of Military

Date of Entry

Rank

Date of Discharge

PLEASE PROVIDE A COPY OF THE DISCHARGE PAPERS (DD-214)

Number of Death Certificates Requested

Height

Weight

COMPLETE OBITUARY INFORMATION ON BACK SIDE

Religion

Church

List Clubs, Noteworthy Achievements, Etc,

SURVIVING RELATIVES

Father

Mother

Husband / Wife

Sons

Daughters

Brothers

Sisters

Grandchildren (No)

Great Grandchildren (No)

Deceased Relatives

Newspaper Notices

Questions comments and concerns

Additional Charges May Apply

Anti-Spam Security Question

Short North Chapel
| 34 West 2nd Avenue
| Columbus, OH 43201
| Tel: (614) 299-4155
|

Clintonville Chapel
| 4341 North High Street
| Columbus, OH 43214
| Tel: (614) 262-2600
|

In this section

VETERANS INFORMATION

COMPLETE OBITUARY INFORMATION ON BACK SIDE

SURVIVING RELATIVES