Lancaster Decedent Form

Complete the following Information

complete for the person who has died or yourself if this is for a preneed.
Has a Death Occurred?*

YESNo, This is for a PreNeed
Date of Death

MonthDayYear
Place of Death

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name*

First NameMiddle NameLast NameSuffix
Gender*
If Female, Last Name Prior to Marriage
Race*
Is Decedent of Hispanic Origin?*

NOYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanOther
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the Home Address inside the City Limits?*

YesNo
County and State or Country of Birth *
Birth Date*

MonthDayYear
CURRENT AGE*
SSN*
### - ## - ####
Level of Education*
Veteran?*

YesNo
Branch of Military
Marital Status:*

MarriedDivorcedWidowedSeparatedNever Married
Spouses Name (If Female include Maiden Name)
Occupation*
cannot say retired
Industry of Occupation*
Father's Name*

First NameMiddle NameLast NameSuffix
Mother's Maiden Name*

First NameMaiden Name
Please List Survivors ...
Names and Relationship
I am interested in

BurialCremationCemetery PropertyHeadstones or Monuments
Special Instructions
Informant Information

Who is completing this form
Informant Name*
Relationship to Decedent
Informant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Informant Home Phone Number

Area CodePhone Number
Informant CellPhone

Area CodePhone Number
Informant Email*
example@example.com
I certify that the above information is accurate and correct, if a death has occured the information will be used to complete the death certificate. I understand that if changes to the death certificate are needed after it has been signed by a doctor or certified , I will be subject to a $100.00 charge for corrections
If you would like to upload a file such as a DD214 or Health Care Power of Attorney form, you may attach that here

Browse Files
Upload a file such as a DD214 or Health Care Power of Attorney form here Cancelof
Should be Empty:

Complete the following Information

Informant Information