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 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
Race
Marital Status as of This Date
Name of Spouse (maiden name, if wife)
- check if spouse is deceased
In Armed Forces
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)
Higher Education
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 State ZIP Code
Phone Number
Email

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Online Pre-Need Form (prior to a death occuring)

Vital Statistics (Basic Information)

Family Information

Children (oldest to youngest with spouse info, phone number and email address if applicable))

Additional Notes

Person Completing This Form

No Hidden Fee Guarantee

Accepted Payment Methods

Satisfaction Guarantee