Vital Information

"*" indicates required fields

Step 1 of 2

Please call 570.586.8009 to let the director, on call, know that your loved one is ready to be brought into our care.

Click next to enter your loved one's vital information for the death certificate.

Please write unknown if unknown to the following questions.

Deceased Name*

Full Name

Date of Birth*

Date of Death*

Time of Death (optional)

Place of Death*

Current Location if different from place of death

Family Doctor (if known)

Social Security Number*

Legal Address*

Street Address Address Line 2 City State ZIP Code

Place of Birth*

City State / Province / Region Country

Father's Name

First Last

Mothers's Maiden Name*

First Last

Martial Status*

Occupation*

Industry*

Spouse (optional if not applicable)

First Last

Your Name*

First Last

Your Email*

Your Phone*

Your Address*

Street Address Address Line 2 City State ZIP Code

Your Relationship*

Legal Next of Kin

First Last

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