Online Arrangement Form

DECEDENT’S LEGAL NAME*

FIRST NAME LAST NAME

SEX

U.S. SOCIAL SECURITY NUMBER

Number
None
Unknown

U.S. SOCIAL SECURITY NUMBER

The SSN is required to complete the arrangements. If you don’t feel comfortable entering the information here, we will call you by telephone to retrieve the SSN.

PLACE OF DEATH

PLACE OF DEATH FACILITY NAME

DATE OF DEATH

DATE OF BIRTH

AGE

DECEDENT’S BIRTH COUNTRY

United States
Mexico
Other

DECEDENT’S BIRTH PLACE

City State

DECEDENT’S BIRTH PLACE

City State / Province / Region

EVER IN U.S. ARMED FORCES?

DECEDENT’S NAME PRIOR TO FIRST MARRIAGE

DECEDENT'S RESIDENCE ADDRESS

STREET ADDRESS CITY STATE ZIP CODE

COUNTY

IN CITY LIMITS?

HOW LONG IN THE STATE OF ARIZONA?

Number

MARITAL STATUS

RESIDED IN AZ. TRIBAL COMMUNITY?

Yes
No
Unknown

If yes, list name of Arizona Tribal Community on the line below

SPOUSE'S NAME

FIRST NAME MIDDLE NAME MAIDEN NAME SUFFIX

FATHER'S NAME

FIRST NAME MIDDLE NAME LAST NAME SUFFIX

MOTHER'S NAME

FIRST NAME MIDDLE NAME MAIDEN NAME SUFFIX

INFORMANT'S NAME

FIRST NAME LAST NAME

RELATIONSHIP TO DECEDENT

INFORMANT’S EMAIL ADDRESS*

INFORMANT’S PHONE NUMBER

INFORMANT’S MAILING ADDRESS

METHOD OF DISPOSITION

EDUCATION

DECEDENT'S OCCUPATION

If not known, enter UNKNOWN

DECEDENT'S INDUSTRY

If not known, enter UNKNOWN

DECEDENT’S HISPANIC ORIGIN

Check the boxes that best corresponds with the decedent’s ethnic identity as given by the informant

No, Not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, Other Spanish/Hispanic/Latino
Not Obtainable
Unknown
Refused
Other (Specify)

OTHER SPANISH/HISPANIC/LATINO

OTHERS DECEDENT’S HISPANIC ORIGIN:, SPECIFY

DECEDENT’S RACE

Enrolled Tribe

Secondary Tribe

Other Asian (Specify)

Other Pacific Islander (Specify)

Other (Specify)

Phone

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

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