Pre Planning Form

New Day Vitals Worksheet

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

Vital Statistics Worksheet

Information about the person who has passed away

First:

Prefix:

Middle:

Suffix:

Last

Maiden Name:

Other Names/AKA:

Marital Status (circle one):

MarriedWidowedDivorcedNever-married

Date of Birth:

Age:

Race:

Birthplace:

Citizenship:

Legal Street Address:

Address Line 2:

Apt#:

Street

City

State/Province

ZIP/Postcode

Care Facility name if applicable:

SS#:

Highest School Grade or Type of College Degree:

Primay job or occupation when of working age:

Veteran?:

YesNo

Branch of Service:

If yes, what rank?:

What year(s)?:

Please note that a copy of an honorable discharge document is required to apply for veteran benefits,

or for veteran information to appear on the final death certificate.

Father’s Name:

Mother’s Name:

Birthplace:

Please provide a maiden name or names if applicable.

Person in charge of funeral arrangements

Full Name:

Primary phone #:

Relationship to deceased:

Email Address:

Street Addr:

Apt#:

City:

State:

Zip:

465 County St
| New Bedford, MA 02740
| Tel: 1-508-992-5486

1-833-6NEWDAY
1-833-663-9329

How Can We Help?

465 County St
| New Bedford, MA 02740
| Tel: 1-508-992-5486

1-833-6NEWDAY
1-833-663-9329