DOSA: Dedicated Organization for Service and Assistance

Facts of Death Verification

as they will appear on the Certificate of Death

First Name *

Middle Name

Last Name *

Date of Birth

Date of Death

Age

Birth City

Birth State or Foreign Country

Social Security

Surviving Spouse's Name

Residence Street Address

Apt.No

City or Town

Country

State

Zip Code

Highest level of Education

Occupation

First Name of the Father

Last Name of the Father

First Name of the Mother

Last Name of the Mother(Before to marriage)

Country Of Death

City Of Death

Zipcode Of Death

Informant's Name

Relationship To Deceased

Informant Mailing Address(Street and Number)

Informant Mailing Address(City)

Informant Mailing Address(State)

Informant Mailing Address(ZipCode)

Place Of Disposition(Name Of Cemetery)

Location(Country)

Location(City/Town)

Location(State)