FIELD NAME

INSTRUCTIONS

1a. Legal Name of Decedent (First, Middle, Last, Suffix)

The full first, middle and last name of the decedent.  Do not abbreviate.  If applicable, enter a valid suffix (Sr., Jr., I, II, III, IV, V, VI, VII, VIII, IX, X). Note this field is filled out during the initial stage of creating a case.

1b. Also Known As (AKA), If any (First, Middle, Last, Suffix)

Enter the full first, middle and last alias name of the decedent.  Do not abbreviate.  If applicable, enter a valid suffix (Sr., Jr., I, II, III, IV, V, VI, VII, VIII, IX, X). DO NOT INCLUDE nicknames or Spelling variations of the first name.

2. Sex

Valid entries: Male, Female and Unknown (if sex cannot be determined.)

LIMB ONLY

Check this box if the Death Certificate is being generated to dispose of a limb and no death has occurred.

3. Social Security No.

Enter the decedent’s 9-digit Social Security number.  Other valid entries: “None”, “Unknown” or “Not Obtainable”.

4a. Age

If decedent is 1 year old or over, enter age at last birthday in years (i.e. 9 years)

If decedent is less than 1 year old and greater than 1 month old, enter age in months (i.e. 2 months)

If decedent is less than 1 month old and greater than 24 hours old, enter age in weeks or days (i.e. 2 weeks or 5 days)

If decedent is less than 24 hours old , enter age in hours or minutes (i.e. 12 hours or 30 minutes)

5. Date of Birth (Mo/Day/Yr)

Enter the full name of the month (January, February, etc), day and 4-digit year that the decedent was born.  If the date of birth is unknown, then enter “Unknown”. 

6. Birthplace (City & State/Foreign Country)

If decedent was born in the U.S., enter the name of the City and State.   If not born in the U.S., select country of birth from drop-down list.

7a. Residence – State

Enter decedent’s state of residence.

7b. County

Enter decedent’s county of residence.

7c. Municipality/City

If decedent resided in NJ, enter municipality of residence.  Otherwise enter city of residence. Note: Municipality can be different from the mailing address.

7d. Street and Number

Enter decedent’s number and street of residence.

7e. Apt No.

Enter apartment or room number associated with residence.  If none, leave blank.

7f. Zip Code

Enter the ZIP code of the place where the decedent lived.

7g. Inside City Limits?

If decedent resided in NJ, always enter “Yes”.  If decedent resided outside of NJ other valid entries are “No” or “Unknown”.

8a. Ever in US Armed Forces?

If decedent ever served in the US Armed Forces, enter “Yes”.  Other valid entries, “No” or “Unknown”.

8b. If yes, Name of War

If “Yes” has been entered in field 8a and decedent has served in a military conflict, enter the name of the conflict.  If field 8a is “No”, leave blank.

8c. War Service Dates (From/To)

If field 8b contains the name of a military conflict, enter the From and To dates that the decedent served in the US Armed Forces.

9. Domestic Status at Time of Death

Enter the domestic status of the decedent at time of death.  Specify one of the following: “Married”, “Married, but separated”, “Never married”, “Widowed”, “Divorced”, “Domestic Partner”, “Domestic Partnership Terminated”, “Domestic Partner (Deceased)”, “Civil Union Partner”*, “Civil Union Dissolved”*, “Civil Union (Deceased)”*, “Unknown” or “Not Obtainable”.

* Civil Union can only be used with deaths that occurred after 2/19/2007..

9a. Surviving Spouse’s Name (If wife, give name prior to first marriage)

If the decedent was married at the time of death, enter the full name of the surviving spouse.  If the surviving spouse is a wife, enter her name prior to first marriage (e.g., maiden name). If no surviving spouse, leave this field blank.

10. Name of Surviving Spouse/Partner (List name given at birth or on birth certificate)

If the decedent was married, in a Domestic Partnership or in a Civil Union at the time of death, enter the full name of the surviving spouse/partner. Use the surviving spouse/partner’s name given at birth or on birth certificate. If no surviving spouse/partner, leave this field blank.

11. Father’s Name (First, Middle, Last, Suffix)

Enter the full first, middle and last name of the decedent’s father.  Do not abbreviate.  If applicable, enter a valid suffix (Sr., Jr., I, II, III, IV, V, VI, VII, VIII, IX, X).  If the father’s name cannot be determined, enter “Unknown” in the Last Name field.

12. Mother’s Name (First, Middle, Last, Suffix)

Enter the full first, middle and surname that the decedent’s mother used prior to first marriage, commonly known as the maiden name.  Do not abbreviate.  If applicable, enter a valid suffix (Sr., Jr., I, II, III, IV, V, VI, VII, VIII, IX, X).  If the mother’s name cannot be determined, enter “Unknown” in the Last Name field.

13a. Name of Informant

Enter the full first, middle and last name of the person who supplied the personal facts about the decedent and his or her family.  Do not abbreviate.  If applicable, enter a valid suffix (Sr., Jr., I, II, III, IV, V, VI, VII, VIII, IX, X).

13b. Relationship to Decedent

Enter the relationship of the informant to the decedent.  Specify one of the following: “Child”, “Parent”, “Sibling”, “Spouse”, “Domestic Partner”, “Other Relative” or “Other”

13c. Mailing Address (Street and Number, City, State, Zip Code)

Enter the complete mailing address of the informant whose name appears in item 13a.  Be sure to include the ZIP Code.

14. Method of Disposition

Enter one of the following methods of Disposition: “Burial”, “Cremation”, “Donation”, “Entombment”, “Removal from State” or “Other:”.  If “Other:” is used, specify the method of Disposition in the same space.

15. Place of Disposition (Name of cemetery, crematory, other)

Enter the name of the cemetery, crematory or other place of disposition.  If the body is removed from the State, specify the name of the cemetery, crematory, or other place of disposition to which the body is removed.

16. Location – City or Town and State

Enter the name of the city, town, or village and the State where the place of disposition is located.