On-line At Need Form

To expedite our information gathering process, please fill out and submit the On-line At Need Form below. This information is required for paperwork filed with the State Health Department.

If you'd rather fill out a print version of the form CLICK HERE.

NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

Vital Information On The Deceased For Death Certificate

* Full Name:

* Email Address:

Usual Residence of Deceased:

County:

Marital Status:

Surviving Spouse's Full Name:

Veteran Status
(If yes, please bring in discharge papers):

Yes No

Branch of Service:

Social Security Number:

Date of Birth:

(eg:1999)

Date of Death:

(eg:1999)

Usual Occupation
(most of life):

Business:

Father's Full Name:

Mother's First and Maiden Name:

Highest Level of Education
(number of years completed):

Obituary Information Names of Surviving Relatives: (if multiple, separate full names by commas in each field)
Spouse:
Children:
Parents:
Brother(s):
Sister(s):
Grandchildren:
Great Grandchildren:
Great Great Grandchildren:

Other Information:

At Need Form - Printer-friendly Version:

You can download the printer-friendly version of our At Need Form to your local computer from the link below. Once downloaded, open the PDF *, and enter you information on the form, then print it out on your printer. You may then either mail or fax it to us at the address or fax number below, or bring it with you when you visit.

» CLICK HERE to download the form.

* NOTE: Adobe Acrobat Reader software is required to view this file - if you don't already have the Reader installed on your computer, it is available for free from Adobe's website - please click the icon at right to be taken to the download page.

Mail or bring completed form to this address:
4205 SE 59th Avenue
Portland, Oregon 97206-3851
Please call with any questions: (503) 771-1171