All information requested below is required by the State of Ohio.
Decedents Address*
Apt, Suite, Etc.
City*
State*
Zip Code*
Decedent ever in Armed Forces?*
Decedents Marital Status
Divorced (and not remarried)
Married
Married but Separated
Never Married
Widowed (and not remarried)
Decedents Spouses Last Name**
Decedent of Hispanic Origin?*
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
Decedents Usual Occupation**
Decedents Kind of Business or Industry*
Decedent Location of Death
Decedents Home
Hospital
Nursing Home/ Long Term Care Facility
Other
Please fill out the following to the best of your ability.
Cemetery? (if applicable)
Obituary: (Please indicate how Decedents Name should appear)
Obituary: Spouse (Please indicate how Spouses Name should appear) (if applicable)
Obituary: List Children & Spouses
Obituary: List Brothers & Sisters
Obituary: Parents
Obituary: Grandchildren/ Others
Obituary: Personal Background (Optional)
Obituary: Memorial Contributions (Optional)
