North Carolina Death Certificate

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North Carolina Death Certificate

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Personal Information

Full Name of Deceased

Suffix (Sr., Jr. III, etc.)

Last Name Prior to FIRST Marriage (Maiden Name), if applicable

Date of Birth

Birthplace (COUNTY and State)

Sex

Age

Social Security Number

Date of Death

Place of Death (Choose One)

Facility Name (If death did not occur in a facility, provide street address)

Marital Status

Surviving Spouse's Full Name (If Widowed/Divorced, Leave Blank)

Decedent's Usual Occupation (DO NOT PUT RETIRED. Instead, use last job worked)

Kind of Business/Industry (Education, Healthcare, Law Enforcement, Private, etc.)

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Decedent's Residence

Street

City

State/Providence

Zip/Postcode

County

Is Residence in City Limits?

Yes

Unknown

Did Decedent Serve in US Armed Forces?

Branch of Military (Leave blank if NA)

Decedent's Highest Level of Education

Is Decedent of Hispanic Origin?

Decedent's Race

Father's Full Name (If unknown, write unknown)

Mother's Full Name (Include Maiden Name)

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Informant Information (Next of Kin)

Informant's Name

Informant's Relationship to Deceased

Informant's Telephone #

Informant's Email Address

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Final Disposition

Method of Disposition

Name of Cemetery (Include City and State). If cremation, leave blank

K. N. Jones Memorial Care, LLC

North Carolina death certificate

North carolina death certificate

North Carolina Death Certificate

k.n. jones memorial care, llc

H.D. Weaver Memorial Chapel