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Vital Statistics Form

Filling out a Vital Statistics form is a crucial step in the funeral planning process. This form gathers essential information about your loved one, which is necessary for legal documentation and creating a meaningful tribute. At Scott County Cremation, we are here to assist you in completing this form accurately and efficiently, ensuring all details are handled with care and respect.

If you have any questions, or would like assistance with this form please contact us.

Immediate Need Form

Free Text

Personal Information of Deceased

Legal Name of Deceased*

Street Address*

City*

State*

Zip*

In City Limits?

County*

Date of Death*

Time of Death

Place of Death

Doctor's Name

Clinic & Phone Number

Sex*

Race

Marital Status

Social Security Number*

Age*

Date of Birth*

Place of Birth (city, state)

Name of Father

Name of Mother (including mother's maiden name)

Occupation

Business of Industry

Education (highest level completed)

Date of Marriage

Place of Marriage

Spouse Name (including maiden name)

Spouse DOB/DOD

Spouse SSN

Veteran*

Does the deceased have a pacemaker or any implant containing a battery?

Yes

Free Text

Informant Information

Name*

Relationship to the Deceased

Street Address*

City*

State*

Zip*

Phone Number*

Number of Death Certificates Needed ($13 for the first copy and $6 for each additional)

Free Text

General Price List Acknowledgement

General Price List Acknowledgement

I was offered the General Price List

Free Text

CLICK HERE TO OPEN GENERAL PRICE LIST

By checking the button I acknowledge that per MN and Federal Laws I/we were offered for retention on the home page of this web site, a General Price List that contains the Alternative Container Price List and Urn Price List. Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. MN Law Requires use of Alternative Container, MN Law Requires Medical Examiner Cremation Authorization.

Free Text

Agreement

Agreement

I agree to terms and electronic signature

Free Text

By electronically signing below and clicking above I acknowledge and agree to pay for the final services of the deceased, and I authorize Scott County Cremation to perform the requested services. I agree to pay the balance listed on this statement. Total charges are due the date of this agreement. I understand and agree that by signing below I am assuming personal liability for the charges set forth in this statement. Late fees will be charged if not paid on date of agreement. I herby agree to all above charges and acknowledge receipt provided by email or will be provided upon release of cremated remains.

Free Text

Electronic Signature

Type name here:

Electronic Signature

New Field:

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Vital Statistics Form

Immediate Need Form

A Year of Grief Support

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