Death Certificate Information Form

Download a list of recommended items that may be needed for the arrangement.

Click on the graphic on the left to download the file.

Please fill out the following form only if instructed by one of our directors.

Name of Person Responsible for Arrangements

Person Responsible for Arrangement Phone Number

If any information is unknown, please type "Unknown" in the form field. All fields are required.

Name of Deceased

Please note: A Social Security Number for your loved one will be required at the time of the arrangement conference.

Date of Birth

Gender

Age

Place of Birth (City and State are both required)

Address of Residence

Marital Status

Surviving Spouse (maiden name) or type NA if not applicable.

Military Service or type NA if not applicable.

Father's Name (First, Middle, Last)

Mother's Name (First, Middle, Maiden)

Next of Kin's Name

Father's Birth Place (State only or Country if outside of USA)

Mother's Birth Place (State only or Country if outside of USA)

Next of Kin's Relationship to Deceased

Next of Kin's Address (Street, City, State, Zip)

Decedent's Usual Occupation

Decedents Race

Highest Level of Education

Kind of Business/Industry (ex: retail, food service etc.)

Decedent of Hispanic Origin?

Next of Kin's Phone Nome Number

Use the following to upload a .PDF or .JPG copy of Decedents DD214 or a photo of the deceased. (not required.)

Upload DD214 Form or photo of deceased (if available)

Buck-Murphy Funeral Home & Cremation Services
| 825 E 17th Street
| Idaho Falls, ID 83404
| Tel: 1-208-522-7424
|

825 E 17th Street
| Idaho Falls, ID 83404
| Tel: 1-208-522-7424
| Fax: 1 -208-522-7428

Buck-Murphy Funeral Home & Cremation Services
| 825 E 17th Street
| Idaho Falls, ID 83404
| Tel: 1-208-522-7424
|

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