Information Form | Hill & Kunselman Funeral Home, Inc. | Beaver Falls PA funeral home and cremation

Information About the Person Completing This Form

First Name

Last Name

Middle Name

Street

City

State/Province

ZIP/Postcode

Email Address

Telephone

Person for whom I am filling for:

Deceased Vital Statistics for Death Certificate

Deceased First Name

Deceased Last Name

Middle Name

Race

Gender

Date of Birth

Place of Birth, City, State, County ( if outside of USA country)

Social Security Number

Father's Full Name

Mother's Full Name ( Include Maiden Name)

Place of Death

City of Death

State of Death

County of Death

Location of Deceased now

Education

Usual Occupation (most of life)

Kind of Business

Company

Company Location

Marital Status

Full Name of Surviving Spouse

Spouse Name, (Provide Maiden Name)

Deceased Mailing Address

Street

City

State/Province

ZIP/Postcode

City /Township/ or Boro

Veteran Information

Was Decendent Ever In the US Armed Forces?

Branch of Service

Date Enlisted

Date Discharge

Honorable Discharge

Military Serial Number

Is a copy of discharge papers available?

Informant/Person In Charge Information

First Name

Last Name

Middle Name

Relationship to deceased

Email Address

Street

City

State/Province

ZIP/Postcode

For Cremation Only Legal next of kin must sign authorization for cremation. Legal authority as follows.

IF no spouse list the following next of kin

All living Children (over 18 years old)

If no children, Parents Living

If no children nor living parents

Sibling ( brother or sisters living)

If no living relatives person authorized for arrangements

Additional information

In this section

Deceased Vital Statistics for Death Certificate

Veteran Information

Informant/Person In Charge Information