3801 4th Avenue
| Beaver Falls, PA 15010
Tel: 1-724-843-1200
Information About the Person Completing This Form

Deceased Vital Statistics for Death Certificate

Veteran Information

Informant/Person In Charge Information

Please complete the following for obituary information.

All Surviving relatives to be listed in the obituary         

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

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