Please complete this form then we will mail you documentation that discusses next steps. If you have questions prior to our contacting you please call 717-273-6283 and mention that you are completing pre-arrangements online. Today's Date MM slash DD slash YYYY Vital Statistics (Basic Information)Please complete the fields below with the information of the person to whom the prearrangements are intended for. This information will be used to file the death certificate at the time of death and is kept in strict confidence. If you do not know the answer to any of the below questions please enter the word, 'Unknown' in the appropriate field. First Name Middle Name Last Name Social Security Number Phone numberCell Phone (if applicable)Email Legal Residence 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 $150 will be assessed for transfers requiring additional staff members (i.e. deaths occurring at a residence).Boro or Twp of Residence County of Residence Date of Birth MM slash DD slash YYYY Birthplace: (City) Birthplace: (State) Birthplace: (County) Birthplace: (Country) U.S. Citizen Yes No SexMaleFemaleRaceCaucasianAfrican AmericanHispanicAsianOtherMarital Status as of This DateMarriedNever MarriedWidowedDivorcedName of Spouse (maiden name, if wife) check if spouse is deceased In Armed ForcesYesNoNot 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@CremationLancasterPA.com (please do NOT send originals) Usual Occupation While many people have had many different occupations throughout their career, please choose the one that best represents the individual.Kind of Business/Industry i.e. manufacturing, retail, medical, laborer, etcEducation (highest completed) Elementary & Primary (0-12)123456789101112Higher EducationNoneSome College CreditAssociates DegreeBachelors DegreeMasters DegreeDoctorate/Professional DegreeNote: Higher education does NOT include technical, trade, or business schools.HiddenDoes the Individual 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. Is a Pacemaker Present? Yes No Not Sure 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.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.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 father is deceased 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.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.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.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.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 mother is deceased Please Check One of the Following Options Ship Cremated Remains ($200 fee) Hold Cremated Remains for Pick-up Not Sure Yet Where the remains should be shipped to? Family InformationChildren (oldest to youngest with spouse info, phone number and email address if applicable))If children are deceased, please type "deceased" before the respective name.First (Spouse) Last. Phone Number. Email AddressExample: Mike (Sally) Jones. (717) 555-5555. jsmith@gmail.comAdditional Notesplease provide us with any other information that you feel is pertinent.Additional Notes (optional)Person Completing This FormI am Completing This Form For: Myself My Spouse/Partner My Parent If choosing an option other than "myself" please provide your contact information below.Legal Name First Last Legal Residence 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 Phone NumberEmail Total $0.00 CAPTCHA
