VITAL STATISTICS INFORMATION

Email

NAME

Gender
MaleFemale

Birthdate

Birthplace (including county)

ADDRESS

Street

Township

Boro/City

State or Country

County

Zip Code

Veteran?YesNo

Martial Status —Please choose an option—MarriedWidowedDivorcedNever Married

Spouse (Including Maiden Name)

Father's Name

Mother's Name (Including Maiden Name)

Race

Occupation

Education
8TH GRADE OR LESSNO DIPLOMA (9TH—12TH GRADE)HIGH SCHOOL OR GEDSOME COLLEGE CREDITASSOCIATE DEGREEBACHELOR’S DEGREEMASTER’S DEGREEDOCTORATE

INFORMANT

Name

Relationship

Informant Mailing Address

Informant Phone Number

Current Location

—Please choose an option—Hospital: INPATIENT Hospital: ER/OUTPATIENTHospiceNursing HomeResidenceOther

Facility Name (if appropriate)

Facility Address

County

Cemetery Name

Cemetery Address

BurialCremationRemoval from StateDonation

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