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Online Arrangement Form (after death has occurred)
Online Pre-Need Form (prior to a death occuring)
Cremation Authorization Form, Printable
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Covid-19
Relief Supplemental Appropriations Act of 2021
Online Pre-Need Form (prior to a death occuring)
Please complete this form then we will mail you documentation that discusses next steps. If you have questions prior to our contacting you please call
717-273-6283
and mention that you are completing pre-arrangements online.
Today's Date
MM slash DD slash YYYY
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 number
Cell Phone (if applicable)
Email
Legal Residence
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please note: An additional charge of $100 will be assessed for transfers requiring additional staff members (i.e. deaths occurring at a residence).
Boro or Twp of Residence
County of Residence
Date of Birth
MM slash DD slash YYYY
Birthplace: (City)
Birthplace: (State)
Birthplace: (County)
Birthplace: (Country)
U.S. Citizen
Yes
No
Sex
Male
Female
Race
Caucasian
African American
Hispanic
Asian
Other
Marital Status as of This Date
Married
Never Married
Widowed
Divorced
Name of Spouse (maiden name, if wife)
check if spouse is deceased
In Armed Forces
Yes
No
Not Sure
Deceased 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@CremationLancasterPA.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, etc
Education (highest completed) Elementary & Primary (0-12)
1
2
3
4
5
6
7
8
9
10
11
12
Higher Education
None
Some College Credit
Associates Degree
Bachelors Degree
Masters Degree
Doctorate/Professional Degree
Note: Higher education does NOT include technical, trade, or business schools.
Does the Individual Weigh More Than 400 Lbs?
Yes
No
Not Sure
We realize that this is a sensitive question however please note that a surcharge of $600 will be assessed if "yes." This fee is to cover additional cremation time and the additional staff that is needed.
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 ($125 fee)
Hold Cremated Remains for Pick-up
Not Sure Yet
Where the remains should be shipped to?
Family Information
Children (oldest to youngest with spouse info, phone number and email address if applicable))
If children are deceased, please type "deceased" before the respective name.
First (Spouse) Last. Phone Number. Email Address
Example: Mike (Sally) Jones. (717) 555-5555. jsmith@gmail.com
Additional Notes
please provide us with any other information that you feel is pertinent.
Additional Notes (optional)
Person Completing This Form
I am Completing This Form For:
Myself
My Spouse/Partner
My Parent
If choosing an option other than "myself" please provide your contact information below.
Legal Name
First
Last
Legal Residence
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
Email
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