Purely Cremations

A Subsidiary of Starks Family Funeral Homes

Have Questions ? Call us: (269) 926-9440

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Certificate of Death

  • (First, Middle, Last)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • :
  • Hospital or Institution - Name (If not in either, give street, and number and zip code
  • What is the highest degree or level of school completed at the time of death?
  • American, Indian, White, Black, (If Asian, give nationality, ie. Chinese, Filipinos, Asian Indian, etc.) (Enter all the apply)
  • Mexican, Cuban, Arab, African, English, French, Dutch, etc. (Enter all that apply) If American Indian race, enter principal tribe
  • Give kind of work done during most of working life. Do not use retired.
  • (if wife, give name before first married)
  • (First, Middle, Last)
  • (First, Middle, Last)
  • (Type/Print)
  • Burial, Cremation, Entombment, Donation, Removal, Storage(Specify)
  • (Name of Cemetery, Crematory, or other location)
  • (of licensee)
  • Date Format: MM slash DD slash YYYY
  • :
  • Date Format: MM slash DD slash YYYY
  • :
  • (Home, Hospice, Nursing Home, Hospital, Ambulance) Specify
  • (Home, Hospice, Nursing Home, Hospital, Ambulance) Specify
  • (If applicable)
  • (Type or Print)
  • Date Format: MM slash DD slash YYYY
  • PART I. Enter the chain of events -diseases or Complications - that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. Enter only once cause on a line.

     

  • If diabetes was an immediate, underlying of contributing cause of death be sure to record diabetes in either Part I or Part II of the cause of death section as appropriate.
  • Immediate Cause (Final disease or condition resulting in death)
  • Sequentially list conditionIF ANY, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or inquiry that initiated the events resulting in death) LAST
  • Date Format: MM slash DD slash YYYY
  • :
  • At home, farm, street, construction site, wooded area, etc.,(specify)
  • Driver/Operator, Passenger, Pedestrian, etc.,(Specify)
  • This field is for validation purposes and should be left unchanged.

Ask the Director

  • This field is for validation purposes and should be left unchanged.

Download Our Resource Kit

St-Joseph-Funeral-Cremation-Resource-Kit

Testimonials

From Hunter & Lauren, & Scott Cole

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