Connecticut Cremation Service

For information needed to complete The Connecticut State Death Certificate
Name:_______________________
Date of Birth:__________________
Race:________________________
Social Security #:________________
Highest Degree of Education:___________________
City and State of Birth:________________________
Occupation and Industry:________________________
Home Address:________________________________
Marital Status:_________________________________
Name of Last Spouse (Maiden):__________________________Father's Name:________________________________________

Mother's Name (First and Maiden):______________________________
Veteran: Yes or No
Information of person filling out this form:
Name and relation to deceased:____________________________________________
Address:____________________________________  Telephone:__________________
Follow link above to CT Permit and sign in part 3. On Evergreen Permit sign on the bottom "signature of agent" we will fill out the rest. Send all 3 pages back to: Connecticut Cremation Service 1368 State St. New Haven, CT 06511

Email to gjmenta@yahoo.com or fax 203-772-3092