Midlothian Funeral Home | Midlothian, TX

Vital Statistic Form

Vital Statistic Form (This is used for the top portion of Death Certificate)

Full Legal Name

Maiden

Date of Birth

Birth City, State

County

SSN

Address

City

State

Zip

County

In City Limits

Race

Education

Armed Services

Branch

Texas Peace Officer

Occupation (Prior to Retirement)

Type of Business

Marital Status

Married

Widowed

Never Married

Divorced

Surviving Spouse Name (Prior to Marriage/Maiden)

SSN

Date of Birth

Father's Name

Mother’s Name (Prior to Marriage/Maiden)

Free Text

Informant/NOK (Next of Kin) Per Texas Funeral Commission State Law, the order must be:

Spouse
Adult Children
Parents
Adult Siblings
Adult Nieces or Nephews (if none are available)

Free Text

If no eligible family members are available, an Appointment of Agent to control Disposition is required for Midlothian Funeral Home to serve our families.

Full Legal Name

SSN

Date of Birth

Relationship

Address

City

State

Zip

County

Cell Number

Home Number

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View information for consumers relating to the purchase of preneed funeral contracts including descriptions of the trust and insurance funding options available under state law.

Complaints concerning perpetual care cemeteries or prepaid contracts should be directed to: Texas Department of Banking, 2601 North Lamar Blvd., Austin, TX 78705; 972-723-9884 (toll free); www.dob.texas.gov