Information Required to File a Death CertificatePlease complete the fields below. This information is only used for filing a death certificate and is kept in strict confidence.Person Making Arrangements (Contact Person)Note: the person making arrangements will be listed as the "informant" on the Death Certificate. The "informant” is simply the person providing the decedent's personal information. Normally this person is the "next of kin" such as: son, daughter, spouse, or other relative; or executor or attorney for estate.First Name of Contact Person Middle Name of Contact Person Last Name of Contact Person Phone Number of Contact PersonContact Person's Relationship to Deceased Deceased Person's InformationLegal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's First Name Decedent's Middle Name Decedent's Last Name Decedent's Social Security Number Decedent's Date of Death MM slash DD slash YYYY Decedent's Place of Death Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Boro or Twp Where Death Occured County Where Death Occured Decedent's Residence (Where they lived most of the time) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Decedent's Boro or Twp of Residence Decedent's County of Residence Decedent's Date of Birth MM slash DD slash YYYY Decedent's Age MM slash DD slash YYYY Decedent's Birthplace: (City) Decedent's Birthplace: (State) Decedent's Birthplace: (County) Decedent's Birthplace: (Country) Was the Decedent a U.S. Citizen Yes No Sex of DecedentMaleFemaleDecedent's RaceCaucasianAfrican AmericanHispanicAsianOtherDecedent's Marital StatusMarriedNever MarriedWidowedDivorcedName of Decedent's Spouse (include maiden name, if wife) Check if Decedent's Spouse is Deceased Was the Decedent In the Armed Forces?YesNoNot SureDeceased individual's discharge papers (DD-214) will be required to receive military death benefits. Please mail us a copy or scan and email to info@LancasterCremations.com (please do NOT send originals) Decedent's Usual Occupation While many individual's have had many different occupations, please choose the one that would best represent the decedent.Decedent's Kind of Business/Industry i.e. manufacturing, retail, medical, laborer, etcDecedent's Education (highest completed) Elementary & Primary (0-12)123456789101112Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's Higher EducationNoneSome College CreditAssociates DegreeBachelors DegreeMasters DegreeDoctorate/Professional DegreeNote: Higher education does NOT include technical, trade, or business schools.Does the Decedent Have a Pacemaker? Yes No Not Sure Decedent's Father's First Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's Father's Middle Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's Father's Last Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field. check if decedent's father is deceased Decedent's Mother's First Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's Mother's Middle Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's Mother's Last Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.Decedent's Mother's Maiden (last) Name Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.. check if decedent's mother is deceased Please Choose One of the Following Options Hold Cremated Remains for Pick-up Deliver to Cemetery for Graveside Service Cemetery InformationCemetery Name Where Cremated Remains Will Be Buried Cemetery Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I want Cremation Services of Lancaster to Provide Clergy Yes No Not Sure Decedent's Denomination If Answered "No" to the Above Questions Provide Decedent's Clergy's Name First Last Decedent's Minister's Phone NumberDecedent's Children (oldest to youngest with spouse info and phone number)If children are deceased, please type "deceased" before the respective name.First (Spouse) Last. Phone numberExample: Mike (Sally) Jones. (717) 555-5555Additional NotesAdditional Notes (optional)please provide us with any other information that you feel is pertinent.
