Vital Statistics

Name (first, middle, last):

Nickname:

Current Street Address:

County, State, Zip

Former Street Address:

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Years at Former Address:

Date of Birth:

Place of Birth:

Citizen of:

When Retired:

Occupation(s):

Most Recent Employer:

Employer's Location:

Years Employed There:

Social Security Number:

Marital Status:   Married          Divorced          Single          Widowed

Spouse's Name:

Maiden Name:

Your Father's Name:

Your Father's Birthplace:

Your Mother's Maiden Name:

Your Mother's Birthplace:

Veteran's Serial Number:

Military Rank:

Date of Entry into Military:

Date of Military Discharge:

Other Information:

Gibbons Elliston Funeral Home Gibbons Funeral Home Gibbons Family Funeral Home The Oaks Funeral Home

60 South Grant Street 134 South York Road 5917 West Irving Park Road 1201 East Irving Park Road

Hinsdale, Illinois 60521 Elmhurst, Illinois 60126 Chicago, Illinois 60634 Itasca, Illinois 60143

Phone: (630) 323-0275 Phone: (630) 832-0018 Phone: (773) 777-3944 Phone: (630) 250-8588

Fax: (630) 323-0563 Fax: (630) 832-3719 Fax: (773) 777-3295 Fax: (630) 250-8607