Our Vital Statistics form is safe and secure. Once you have completed the form, please click on the Submit button at the bottm of this page. If for any reason you need to start over, clicking the Reset button will clear the form. Once your form has been received, we will review it and give you a call. At that point, you can decide if you would like to set up an appointment with our Family Services Counselor, or simply have us keep your information safely on file.
Vital Statistics
Full Name
Address
City, State and Zip Code
Phone Number
Are You?
Maiden Name
Place of Birth (City, State)
Date of Birth (00/00/0000) Social Security Number
Are you a US citizen?
Schooling
(Select Highest Grade Completed)
College
(Select Highest Grade Completed)
Father's Name
Mother's Maiden Name
Length of residence in this area
Former residence
Usual Occupation
Place of Employment
Type of Business/Industry
How long where you employed there? Retired?
Yes
No
Church Affiliation
Clubs, Organizations, Memberships
Veteran of Service?
Serial #
Time of Service
War
Branch and Rank
Attorney (Name and Phone)
Physician (Name and Phone)
Surviving Relatives - Name, Address and Phone Number
Relationship
Relationship
Relationship
Relationship
Relationship
Relationship
Grandchildren-How Many? Great-Grandchildren-How Many?
Great-Great Grandchildren-How Many?  

 

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Lankford Funeral Home
220 E. New York Avenue
DeLand, FL 32724
386-734-2244

Orange City Chapel
190 S. Holly Avenue
Orange City, FL 32763
386-775-2244

Lankford Funeral Homes & Crematory, 2007