Biographical Information

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When Death Occurs

Biographical Information

Burial Packages

Cremation Packages

We are very sorry for your loss and stand ready to assist you in your time of need. Please used the form to send us information needed for legal papers.

Please call (814) 749-0821 if you do not have access to all of the details below or if you have any questions.

Arrangement Information

Personal Information of Deceased

Decedent's Legal Name (First, Middle, Last, Suffix)

Street

City

State/Province

ZIP/Postcode

County of Death

Social Security Number

Date of Birth

Place of Birth (city, state and county)

Date of Death

Place of Death (city, state and county)

Marital Status at Time of Death

MarriedDivorcedWidowedNever MarriedUnknown

Highest Level of Education

Surviving Spouse Name (if wife, give name prior to first marriage)

Fathers/Parents Name (First, Middle, Last, Suffix)

Mothers/Parents Name prior to First Marriage (first, middle, last)

Name of CemeteryLeave blank if cremating and you are not burying the cremains.

Place of Residence

Decedent's Usual OccupationIndicate type of work done during most of life - Do Not Use Retired

Kind of Business/Industry (e.g. coal industry, auto industry, manufacturing, foodservice, education)

Was the Decedent a Veteran?

YESNO

If Yes...

Physician Information/Preparation Information

Has a Doctor or Coroner Been Notified?

YesNo

If deceased passed at home

Do you permit us to Embalm?

YesNo

Has the Body Been Released For Removal?

YesNo

Do You Permit Us to Cremate the Body?

YesNo

If Yes, Who Has Granted Permission

Relationship

Name of Doctor Signing Death Certificate

Street

City

State/Province

ZIP/Postcode

Business Telephone

Email Address

Personal Information of Person Legally Responsible for Disposition

Informant's Legal Name (First, Middle, Last, Suffix)

Relationship to Deceased

Email Address

Street

City

State/Province

ZIP/Postcode

Primary Phone Number

Secondary Phone Number

Do You Have a Prearrangement on File with Us?

YesNo

If Yes, Under What Name?

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If you need our services immediately, please call us.
We will begin the process of bringing your loved one into our care right away.

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