Campbell County Death Certificates
Death Certificate Information Form
 
 

Please fill out the form below and press submit. If you make an error, simply use your backspace key or press the reset key at the bottom.

INSTRUCTIONS:

  • Information should be as complete as possible. If any fields are blank on certificate, enter "(left blank)" on the form. If a question on this form is not even asked on the certificate, just skip the question on the form.
  • Please enter all information directly from the actual certificate except where indicated otherwise. Add explanations or information contrary to (or in addition to) the certificate, or to further explain something on the certificate, in the "Comments" section at bottom of the form.
  • Please double check your email address. 
Full Name of Deceased: 

**(as it appears on the certificate)


Registration Number
Regisration District
Certificate Number
Residence of Deceased: 
Sex: 
Race: 
Date of Birth:   
Place of Birth: 
Date of Death:   19
Place of Death: 
County of Death: 
Age: 
Marital Status: 
Spouse: 
Age of Spouse, if living: 
If veteran, name of war: 
Social Security Number: 
Occupation: 
Industry or Business: 
Father's Full Name: 
Father's Birthplace: 
Mother's Full Maiden Name: 
Mother's Birthplace: 
Cause of Death: 

  • Due to: 
  • Other Conditions: 
  • Operation?: 
  • Autopsy?: 
If death was due to external causes, fill in the following:
  • Accident, Suicide, or Homicide: 
  • Date of Occurrence:   19
  • Where did the injury occur?: 
  • Did the injury occur in or about home, on farm, in industrial place, in public place?: 
  • While at work: 
  • Means of Injury: 
Informant: 
Informant Address: 
Burial, Removal, or Cremation: 
Date of Burial:   19
Undertaker: 
Address: 
By: 
Date Filed:   19
Registrar: 
Signature: 
Address: 

Your Name: 
Your Email: 
Your relationship to the deceased: 

Comments or Additional Information: 
(Please add any discrepancies here.)

 

 


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