Vital Statistics Form

We feel one of the most caring things anyone can do for their family is to prepare and plan in advance. We understand the need and sensitivity of planning one’s arrangements. Planning eliminates the uncertainty and confusion about one’s wishes.

Please fill in the following spaces below and we will keep all your information on file. If you would like further help with this matter or more information you can call us at (530) 342-9003.

Please Complete Only Those Options That Apply
NOTE: This information is needed for the death certificate only.
For more information on how this information will be used, please view our privacy policy at the end of the form below.
TIP: Press the TAB key to move to each form field

Person Who Filled Out Form
Who Filled Out This Form?*
Your Email*
Your Phone*
Who The Plan is For
This Plan Is For*
Date of Birth*
Month
Day
Year
Social Security Number
Place of Birth
County Lived In
Years Lived In County
Race/Ethnicity
Address
City
State
Zip Code
Marital Status
Spouse's Full Name
Spouse's Maiden Name
Father's Full Name
Father's State of Birth
Mother's Full Name
Mother's Maiden Name
Mother's State of Birth
Grade School Level Completed
College Level Completed
Military Veteran
- No
- Yes
Military Branch of Service
Occupation (Job Title)
Type of Business (Industry)
Years in Occupation
I prefer
- Burial
- Cremation
Please Choose One of the Following
- I would like you to keep my information on file.
- I would like you to keep my information on file and call me for questions.
- Please forward all information to this trusted Newton-Bracewell employee:
Employee to Forward to (optional)
Person in Charge
Person in Charge of Final Arrangements
Person in Charge - Phone
Person in Charge - Email Address
Person in Charge - Street Address
Person in Charge - City
Person in Charge - State
Person in Charge - Zip Code
Person in Charge - Relationship to Person this Plan is For
Special Instructions
Type the Math Answer in the Box
Comments
This field is for validation purposes and should be left unchanged.

PRIVACY POLICY
Newton Bracewell Funeral Homes are committed to respecting the privacy of our website visitors. Any data which you provide us is not shared with third parties unless required by law. Personally identifiable information will not be sold, rented, or exchanged with any other organization or entity unless you are first notified and expressly agree to it.

This website contains links to other websites. We will not be responsible for the accuracy or reliability of any information, advice, data, opinions, or statements found on these websites.

Any changes to these policies will be posted on this page.

Chico

Paradise

Vital Statistics Form

Person Who Filled Out Form

Who The Plan is For

Person in Charge