Please complete this form and we will contact you to discuss next steps. If you have questions prior to our contacting you please call 717-273-6283 and mention that you are completing At-Need Arrangements online. 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 Middle Name Last Name Contact Person Mailing 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 Email Address: Phone Number of Contact PersonRelationship 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. Please note: The word "Unknown" will appear on the certified death certificate. First Name Middle Name 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 Please note: An additional charge of $100 will be assessed for transfers requiring additional staff members (i.e. deaths occurring at a residence).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 Decedent's Birthplace City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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)123456789101112Decedent's Higher EducationNoneSome College CreditAssociates DegreeBachelors DegreeMasters DegreeDoctorate/Professional DegreeNote: Higher education does NOT include technical, trade, or business schools.HiddenDoes the Decedent Weigh More Than 400 Lbs? Yes No Not Sure We realize that this is a sensitive question however please note that a surcharge of $600 will be assessed if "yes." This fee is to cover additional cremation time and the additional staff that is needed.Does the Decedent Have a Pacemaker? Yes No Not Sure Father's Name First Middle Last 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 Mother's Name First Middle Last 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 Check One of the Following Options Ship Cremated Remains ($200 fee) Hold Cremated Remains for Pick-up Where the remains should be shipped to? Decedent's Children (oldest to youngest with spouse info and phone number and email address)If children are deceased, please type "deceased" before the respective name.First (Spouse) Last. Phone number, email addressExample: Mike (Sally) Jones. (717) 555-5555, MJones@gmail.comAdditional NotesAdditional Notes (optional)please provide us with any other information that you feel is pertinent.Total $0.00
