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Connecticut Cremation Service

For information needed to complete The Connecticut State Death Certificate
Name:_______________________
Date of Birth:__________________
Race:________________________
Social Security #:________________
Highest Degree of Education:___________________
City and State of Birth:________________________
Occupation and Industry:________________________
Home Address:________________________________
Martial Status:_________________________________
Name of Last Spouse (Maiden):__________________________

Fathers Name:_________________________________

Mothers Name (Maiden):_________________________________
Veteran: Yes or No
Information of person filling out this form:
Name and relation to deceased:____________________________________________
Address:____________________________________  Telephone:__________________
Please fill out and send back to:Connecticut Cremation Service 1368 State St. New Haven,CT 06511 or fax 203-772-3092