Before burial or cremation can take place, it is necessary to have the following vital information obtained for the death certificate, which is filed and registered at the Clark County Health Department.

Full Legal Name (required):

Birth Date:

Current Age:

Street Address:

City, St, Zip, County:

Contact Name (required):

Contact E-mail (required):

Contact Phone:

Length of time at your current residence:

Do you live inside the city limits?

Phone Number:


U.S. Citizen?  Yes No

Hispanic Origin or Descent?  Yes No

If yes to Hispanic origin or descent, specify: (Cuban, Mexican, Puerto Rican, etc:)

Race You Consider Yourself to be:  Caucasian Asian American Indian African-American Hispanic

Marital Status:  Married Never Married Widowed Divorced

Spouse (if wife, give maiden name):

Father's Full Name:

Mother's Full Name (Include maiden name):

Usual Occupation When Working (Don't use "Retired"):

Type of Industry:


Veteran?  Yes No

Branch of Military:

Primary Physician:

Physician Address/Phone:

Have you used tobacco in the past 15 years?  Yes No

Do you own cemetery property?  Yes No

If yes, where?

Type of Service(s) Preferred (subject to change)

Burial Cremation
Traditional Graveside
Memorial/COL* Direct Burial
Undecided *COL - Celebration of Life


Selected newspaper(s) for obituary:

Memberships (church, clubs, lodge, civic group, etc.):


Flower/Vegetable Gardening Crocheting/Quilting Traveling
Reading Crossword Puzzles Jigsaw Puzzles
Board Games Cards Cooking
Garage Sales TV Computer
Woodworking Fishing/Hunting Outdoors/Hiking/Camping
Photography Music Sports

Other activities:

Noteworthy Awards/Recognition, Work-Related Accomplishments, Educational Achievements, Military Honors, etc.:

Living Family Members:
Name             Relationship             City & State

Deceased Family Members:
Name             Relationship             City & State

# of Grandchildren:

# of Great Grandchildren:

# of Great Great Grandchildren:

Suggested Memorial Donations (optional):