VITAL STATISTICS RECORD
NAME:
E-MAIL:
DATE OF BIRTH:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
(ex.1999)
PLACE OF BIRTH:
SOCIAL SECURITY NUMBER:
RACE:
HISPANIC/SPANISH/LATINO
YES
NO
MILITARY SERVICE:
YES
NO
BRANCH:
RANK:
YEARS:
MARITAL STATUS (Circle one):
Status
Married
Widowed
Divorced
Never Married
YEARS OF EDUCATION
DEGREE EARNED:
OCCUPATION (Prior to retirement):
TYPE OF INDUSTRY/BUSINESS:
EMPLOYER:
YEARS IN OCCUPATION:
RESIDENCE:
RESIDENCE:
NUMBER OF YEARS RESIDING IN COUNTY:
SPOUSE:
FATHER:
FATHER’S DATE OF BIRTH:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
(ex.1999)
FATHER’S PLACE OF BIRTH
MOTHER:
MOTHER’S DATE OF BIRTH:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
(ex.1999)
MOTHER’S PLACE OF BIRTH
Duggan's Serra Mortuary, Westlake Ave. Daly City, CA 94014 (Phone) 650.756.4500 FD 1098
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