Name
Sex
Date of Death
Age
Birthplace
Occupation
Industry
Anatomical Gift?YesNo
In Armed Forces?YesNo
Flag?YesNo
Place of Death—Please choose an option—Hospital - InpatientER/OutpatientDOANursing HomeResidenceOther
If "Other," where?
Facility Name
City of Death
County of Death (Township in PA)
Marital Status—Please choose an option—MarriedNever marriedDivorcedWidowed
Surviving Spouse (maiden name)
Father's Name
Mother's Name (Maiden Surname)
Address
City
County
State
Inside city limits?YesNo
Zip Code
Hispanic?YesNo
Race
Highest Grade Completed—Please choose an option—8th grade or less9th-12th gradeProfessional trade schoolSome college (no degree)Associate degreeBachelor's degreeMaster's degreeDoctorate degree
Informant's name
Relationship to Deceased
Driver's License #
Phone Number
Family Contact Name
TypeBurialRemoval from stateDonationCremationOther
Place of Disposition
Location (city and state)
Δ
