Death Certificate Registration Form

MAHONEY FUNERAL HOME - Master Form

PLEASE BE EXTRA CAREFUL this information cannot be changed or corrected after submission without paying the city or town an affidavit fee and providing supporting evidence

Below is a list of information required to complete the death certificate, (unknown or refusal to answer is acceptable by the Commonwealth of Massachusetts for some fields, those fields are marked with a *, also the state is particular about middle names and initials, if there is no middle name please enter —)

Basic Information - It is information about the deceased

Name*

First

Last

Middle

Sex*

SSN*

Historical Information

Date of Birth

day

month

year

City or Town of Birth*

State of Birth*

Country of Birth*

Ethnicity or Ancestry (Examples Cambodian, Irish)*

Race (Examples: Asian, Black, Hispanic, White)*

Usual Occupation*

Industry*

Highest level of education*

Death Information

Date of Death

Place of Death

Address of death, or name of hospital or nursing home

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country if outside USA

Deceased's Residence as to be placed on Death Certificate

Place

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country if outside USA

Marriage Information

Marital Status (married, never married, widowed, divorced)

Most Recent Spouse Name

First

Last

Middle

Maiden Name

Years Married

(if spouse has passed away, when did they pass)

Parents Of The Deceased (if unknown please enter unknown)

Fathers Name*

First

Last

Middle

Fathers Place of birth*

Mothers Name*

First

Last

Middle

Mothers Maiden Name*

Mothers place of birth*

Veteran Information (if applicable)

Was the decedent a veteran

Date of Enlist - Date of Discharge

Highest Rank

Service Number

War

Next of Kin information, in most situations person completing this form should be the deceased next of kin. Order of kinship in Massachusetts is Spouse, Child (Guardian of child if child is a minor), sibling, other family member, friend. On the death certificate, this person is the "informant".

Informant Name

First

Last

Middle

Relationship to deceased

Informant Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Informant Phone*

Informant Email*

I certify that I am the legal next of kin of the deceased, or the closest living relative that is able to carry out funeral arrangements. I am the*

Next of kin

Closest living relative able to make funeral arrangements

The following information is only needed if we would like the funeral home to write an obituary for the deceased. Placement on our website and facebook page is included, newspaper placement is an extra fee depending on each publication.

Member of

Religious Affiliation and place of Worship

Hobbies

Previous places of employment

Past lifetime achievements

Places lived

Word Verification

* After Submitting the form you will be redirected to Select Packages and make the payment.