Name
Sex
Date of Death
Age
Birthplace
Occupation
Industry
Anatomical Gift?YesNo
In Armed Forces?YesNo
Flag?YesNo
Place of Death---Hospital - InpatientER/OutpatientDOANursing HomeResidenceOther
If "Other," where?
Facility Name
City of Death
County of Death (Township in PA)
Marital Status---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---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)
