Please fill out this form and we will get in touch with you shortly. Today's date 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 Boro or Twp of Residence County of Residence Date of Birth DD slash MM 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@LancasterCremations.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.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 Hold Cremated Remains for Pick-up Unattended Coastal Scattering Not Sure Yet Where the remains should be shipped to? Family InformationChildren (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 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/In-Law If choosing an option other than "myself" please provide your contact information below.Legal Name First Last Phone NumberEmail
