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Required Information (Death Certificate)

This information will be printed on the death certificate. Please check for accuracy. The death certificate cannot be filed until all of the information has been completed. The state of PA charges $6.00 for each death certificate. Corrected death certificates are also $6.00 a copy.

I am planning for:

My Name:

My Phone:

My Email

Decedent's Legal Name (First, Middle, Last, Suffix):

Sex:

Social Security #:

Date of Death (If Applicable):

Date of Birth:

City of Birth:

Place of Death (If Applicable):

Address of Residence:

Marital Status:

Spouse's First & Last Name (Include maiden name of spouse if applicable):

Father's First & Last Name:

Mother's First Name and Maiden Name:

Next of Kin's Name (Will be listed as informant on Death Certificate):

Next of Kin's Relation to the Deceased:

Next of Kin's Mailing Address:

Ever In Armed Forces?

Highest Level of Education:

Hispanic Origin?:

Decedent's Race:

Usual Occupation (DO NOT USE RETIRED) :

Industry:

Number of Death Certificates Requested

Verification* - Please check the box below then click the submit button. This helps ensure that each entry is submitted by a real person.

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