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? *

YES No, This is for a PreNeed
Date of Death

Month Day Year
Place of Death

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name *

First Name Middle Name Last Name Suffix
Gender *
If Female, Last Name Prior to Marriage
Race *
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Is the Home Address inside the City Limits?

Yes No
County and State or Country of Birth *
Birth Date *

Month Day Year
CURRENT AGE *
SSN *
### - ## - ####
Level of Education *
Veteran? *

Yes No
Branch of Military
Marital Status: *

Married Divorced Widowed Separated Never Married
Spouses Name (If Female include Maiden Name)
Occupation *
cannot say retired
Industry of Occupation *
Father's Name *

First Name Middle Name Last Name Suffix
Mother's Maiden Name *

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

Burial Cremation Cemetery Property Headstones or Monuments
Special Instructions
Informant Information

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Informant Home Phone Number

Area Code Phone Number
Informant CellPhone

Area Code Phone 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
Should be Empty:

Complete the following Information

Informant Information