JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Background Information
Please fill out the following to the best of your ability. All information requested below is required by the state of Ohio.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Cell Phone
*
Your answer
Decedents First Name
*
Your answer
Decedents Middle Name
Your answer
Decedents Last Name
*
Your answer
Decedents Sex
*
Male
Female
Decedents Social Security Number (000-00-0000)
*
Your answer
Decedents Date of Passing
*
MM
/
DD
/
YYYY
Decedents Time of passing
Time
:
AM
PM
Decedents Date of Birth
*
MM
/
DD
/
YYYY
Decedents Age
Your answer
Decedents State of Birth/ Territory
*
Your answer
Decedents City of Birth
*
Your answer
Decedents Residence (Address, City, State)
*
Your answer
Decedent ever in Armed Forces?
*
Yes
No
Decedents Marital Status
*
Divorced (and not remarried)
Married
Married but Separated
Never Married
Widowed (and not remarried)
Decedents Spouse's First Name
*
Your answer
Decedents Spouses Last Name (If Wife, give name prior to First Marriage)
*
Your answer
Decedents Level of Education
*
8th Grade or Less
9th-12th No Diploma
High School Diploma or GED
College but No Degree
Associate Degree
Bachelors Degree
Masters Degree
PHD/Doctorate
Decedent of Hispanic Origin?
*
No
Mexican, Mexican American or Chicano
Puerto Rican
Cuban
Decedents Race
*
White
Black or African American
American Indian or Alaskan Native
Korean
Vietnamese
Other Asian
Other Pacific Islander
Decedents Usual Occupation (do not use retired)
*
Your answer
Decedents Kind of Business or Industry
*
Your answer
Decedents Fathers First Name
*
Your answer
Decedents Fathers Last Name
*
Your answer
Decedents Mothers First Name
*
Your answer
Decedents Mothers Last Name (Prior to First Marriage)
*
Your answer
Informant First Name (Person to be listed as Next of Kin)
*
Your answer
Informant Last Name
*
Your answer
Informant Relationship to Decedent
*
Daughter
Father
Husband
Mother
Other
Son
Spouse
Wife
Informant Address (Address, City, State, Zip)
*
Your answer
Decedent Location of Death
*
Decedents Home
Hospital
Nursing Home/ Long Term Care Facility
Other:
Cemetery? (if applicable)
Your answer
Obituary: (Please indicate how Decedents Name should appear)
Your answer
Obituary: Spouse (Please indicate how Spouses Name should appear) (if applicable)
Your answer
Obituary: List Children & Spouses
Your answer
Obituary: List Brothers & Sisters
Your answer
Obituary: Parents
Your answer
Obituary: Grandchildren/ Others
Your answer
Obituary: Personal Background (Optional)
Your answer
Obituary: Memorial Contributions (Optional)
Your answer
Obituary in Newspaper?
Yes
No
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
