Deceased First Name * You must enter a valid first name

Deceased Middle Name You must enter a valid middle name

Deceased Last Name * You must enter a valid last name

Street Address

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State

Zip Code

Date of Birth *

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Birth City * You must enter a valid city

Birth State / Province * You must enter a valid state/province

Was deceased of Hispanic origin? No Yes, Mexican-American or Chicano Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic or Latino

Marital Status * Marital Status Divorced Married Married, but separated Never Married Single Common Law Unknown Widowed You must select a status

Spouse's First Name

Spouse's Last Name

Spouse's Maiden Name

Mother's First Name

Mother's Last Name

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Father's First Name

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Education Level Unknown Unavailable Elementary/Secondary: 0 Elementary/Secondary: 1 Elementary/Secondary: 2 Elementary/Secondary: 3 Elementary/Secondary: 4 Elementary/Secondary: 5 Elementary/Secondary: 6 Elementary/Secondary: 7 Elementary/Secondary: 8 Elementary/Secondary: 9 Elementary/Secondary: 10 Elementary/Secondary: 11 Elementary/Secondary: 12 G.E.D. Diploma Degree Some College Associates Bachelors Masters PhD Professional

Military Service No Yes

 

Occupation (Before Retirement)

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Informant Information

Informant First Name * You must enter a valid first name

Informant Middle Name You must enter a valid middle name

Informant Last Name * You must enter a valid last name

Informant Street Address * You must enter a valid street address

Informant City * You must enter a valid city

Informant State * You must enter a valid state/province

Informant Zip Code * You must enter a valid zip or postal code

Informant Email Address * You must enter a valid email address

Informant Phone * You must enter a valid phone number

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