Batesville

Time of Arrangement M D Y

Name of Deceased for Publication

First Name Middle Name Last Name

Legal Name for Death Certificate

First Name Middle Name Last Name

Main Contact Name Contact Phone Number

Time of Death

Day of Death	Date of Death M D Y

Place of Death

City County State

Attending Physician

Entered Hospital

M D Y

Length of Illness

Days Months Years

Born

M D Y

Age

Years Months Days

Birthplace

City County State

Social Security Number

- -

R.R. Retirement Number

Father's Name

First Name Middle Name Last Name

Father's Place of Birth

Father's Date of Birth	M D Y

Mother's Maiden Name

First Name Middle Name Last Name

Mother's Place of Birth

Mother's Date of Birth	M D Y

Informant Name

First Name Last Name

Informant Address:	Street

City	County		State

Informant Phone Number

Funeral Director

Embalmer