Lansing Funeral Home | Pre-Arrangement Services

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Record of Vital Statistics

This confidential information is required for the completion of a death certificate. Upon completion of this form, it will be immediately e-mailed to our pre-planning experts who will begin the pre-planning process. Once we receive the information we will contact you to discuss next steps. Please fill out as much of the following form as possible to begin the pre-planning process.

Full Legal Name:
E-Mail Address:
Address1:
Address2:
City:
State:
Sex:
Race:	Other:
Citizen Of:
Hispanic Origin:	Yes No
Birthdate:
Birthplace:
Marital Status:	Single Married Widowed Divorced
Name of Spouse:
If Wife, Maiden Name:
Date Married:
Place Married:
If Spouse Is Deceased, Date:
Place of Death:
Education:	0-12 # of Years
Education:	College # of Years
Social Security #:
If you would like, we can contact you to retrieve sensitive information.
Occupation:
Employed By:
Date of Retirement:
Mother's Maiden Name:
Father's Name:
If Veteran, Date of Service