Vital Information Form

The following information will be used for completion of all legal documents. Including, but not limited to, certified death certificates, cremation permits, social security notification and veteran claim forms. Required fields are marked with an "*".

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Vital Information Form 1 of 5
Deceased’s Name*
First Middle Last Suffix
Sex*
- Male
- Female
Birthdate*
Age-Last Birthday (Years)
Address*
Street Address Address Line 2 City State ZIP Code
Under 1 Year
Month
Day
Under 1 Day
Hours
Minutes
Date of Death*
Social Security Number
Birthplace
(City and State or Foreign Country)
Place of Death
(Check only one)
Hospital
- Inpatient
- Emergency Room/Outpatient
- Dead on Arrival
Non-Hospital
- Hospice Facility
- Nursing Home/Long Term Care Facility
- Decedent's Home
Facility Name
(If not institution give street address)
City, Town, or Location of Death
Inside City Limits
- Yes
- No
Marital Status (Specify)*
- Married (but Separated)
- Married
- Widowed
- Divorced
- Never Married
Surviving Spouse's Name
(If wife, give maiden name)
Residence-Street Address
Street Address City State ZIP Code
Inside City Limits?
- Yes
- No
Decedents Usual Occupation
(Indicate type of work done during most of work life)
Kind of Business/Industry
Decedents Race
(Specify the race/races to indicate what decedent considered himself/herself to be. More than one race may be specified)
Specify
Decedents of Hispanic or Haitian origin?
- Yes
- No
(Specify if decedent was of hispanic or haitian origin)
If Yes, Specify
Specify
Decedents Education
(Specify the decedent's highest degree or level of school completed at time of death)
Specify
(Specify the decedent's highest degree or level of school completed at time of death)
Was Decedent Ever In U.S.Armed Forces?
- Yes
- No
Father's Name
(First, Middle, Last, Suffix)
Mother's Name
(First, Middle, Middle Surname)
Informant's Name (First, Middle, Last, Suffix)*
(First, Middle, Last, Suffix)
Relationship to Decedent*
Phone Number*
Email*
Informant's Mailing Address*
Street Address City State ZIP Code
Place of Disposition
(Name of cemetery, crematory, or other place)
Location-State
Method of Disposition
Specifiy
I,
, do hereby acknowledge that the statistical information given for the death certificate regarding the late
is correct.
Enter Name*
Date
Date Format: MM slash DD slash YYYY
Relationship to Deceased
If the Death Certificate must be amended, there will be an 8 week waiting period and a $250.00 processing fee.
Enter Name Again to Confirm*

Designation of Intentions Form 2 of 5
Required fields are marked with an *
Customer's Designation of Intentions
Place of Cremation
Scheduled Date of Cremation
Date Format: MM slash DD slash YYYY
Authorizing Party:
- Copy information from Informant
Name
Address
Street Address City State ZIP Code
Telephone
Relationship to Deceased
Direction for Disposition of Cremains:
1. Return to
2. Burial in
Cemetery
3. Placement in Niche at
Cemetery
4. Other
Cremains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this firm, in the following manner of disposition: Scatter at sea.
Dated
Date Format: MM slash DD slash YYYY
Signature of Authorizing Party*

Application for Cremation Permit Form 3 of 5
To the Office of Vital Records, Department of Health, The City of New York, State of New York
Country of
} SS. (namely or particularly)
being duly sworn deposes and says that
- he
- she
Resides at
Street Address City State ZIP Code
and desires that a permit be issued by the Department of Health of the City of New York for the cremation of the body of
Deceased Name
who died at
on
Date Format: MM slash DD slash YYYY
Deponent's assumption of authority to act is based upon the following:
Deponent further states that the deceased
- did
- did not
express during life the desire to have
- his
- her
remains cremated and
- his
- her
relationship to deceased is
Deponent assumes all responsibility for the cremation of the remains and authorizes
a licensed funeral director, to make arrangements for said disposal.
Subscribed and sworn to before me this
Date Format: MM slash DD slash YYYY
Signature of Informant*
Enter Name Again to Confirm*

Confirmation of Identification Without Viewing Form 4 of 5
Part I. To be completed by Funeral Home representative whenever there is no visual identification
Name of Deceased
Reason visual identification not performed
Describe alternative methods used to confirm identification (e.g., photographs, scars, tattoos, etc.)
Name of individual providing information
Part II. To be completed by next of kin or other legally authorized persons making arrangements
I,
Having declined to make identification through actual viewing of the remains of
Hereby agree to indemnify and hold the All Boro Cremation Services, LLC. and its officers, directors, shareholders, affiliates, agents, employees, successors, and assigns harmless from any and all claims, liabilities, damages, losses, suits or causes of action (including attorney's fees and expense of litigation) brought by any person, firm or corporation or the personal representative thereof, relating to or arising out of such failure to identify.
Signature*
Relation to Deceased*
Print Name*
Date
Date Format: MM slash DD slash YYYY

At-Need Written Statement of Agent Claiming Legal Control of Disposition Form 5 of 5
I,
,hereby represent and asser that I am entitled to control the disposition of the remains of
,who named me as his/her designated agent in a will or written instrument executed pursuant to Section 4201 of the NYS Public Health Law.
Date
Date Format: MM slash DD slash YYYY
Signature of Agent*
Phone
This field is for validation purposes and should be left unchanged.

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All Boro Cremation Services, 1289 Forest Avenue, Suite A, Staten Island, NY NY 10302, United States - Phone: (718) 887-8168 allborocremation@gmail.com Price range: $495

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