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You are here: Home / Pre-Arrangement Form (Online)

Pre-Arrangement Form (Online)

Please complete this form to the best of your ability. If you have questions prior to our contacting you please call 717-394-4097 and mention that you are completing pre-arrangements online.

Today's Date
MM slash DD slash YYYY
Vital Statistics (Basic Information)
Please complete the fields below with the information of the person to whom the prearrangements are intended for. This information will be used to file the death certificate at the time of death and is kept in strict confidence. If you do not know the answer to any of the below questions please enter the word, 'Unknown' in the appropriate field.
First Name
Middle Name
Last Name
Social Security Number
Phone number
Cell Phone (if applicable)
Email
Legal Residence
Street Address City State ZIP Code
Boro or Twp of Residence
County of Residence
Date of Birth
MM slash DD slash YYYY
Birthplace: (City)
Birthplace: (State)
Birthplace: (County)
Birthplace: (Country)
U.S. Citizen
- Yes
- No
Sex
Race
Marital Status as of This Date
Name of Spouse (maiden name, if wife)
- check if spouse is deceased
In Armed Forces
Discharge papers (DD-214) will be required to receive military death benefits. Please mail us a copy or scan and email to info@DeBordSnyder.com or bring to our office. (please do NOT send originals)
Usual Occupation

While many people have had many different occupations throughout their career, please choose the one that best represents the individual.
Kind of Business/Industry

i.e. manufacturing, retail, medical, laborer, etc
Education (highest completed) Elementary & Primary (0-12)
Higher Education
Note: Higher education does NOT include technical, trade, or business schools.
Father's First Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Father's Middle Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Father's Last Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
- check if father is deceased
Mother's First Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Mother's Middle Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Mother's Last Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
Mother's Maiden (last) Name

Legal forms require this information. If you do not know the answer to any of the below questions please enter the word "Unknown" in the appropriate field.
- check if mother is deceased
Please Check One of the Following Options
- Casket Burial
- Cremation
- Body Donation
- Not Sure Yet
Family Information
Children (oldest to youngest with spouse info and phone number)
If children are deceased, please type "deceased" before the respective name.
First (Spouse) Last. Phone Number
Example: Mike (Sally) Jones. (717) 555-5555
Additional Notes
please provide us with any other information that you feel is pertinent.
Additional Notes (optional)
Person Completing This Form
I am Completing This Form For:
- Myself
- My Spouse/Partner
- My Parent/In-Law
If choosing an option other than "myself" please provide your contact information below.
Legal Name
First Last
Legal Residence
Street Address City State ZIP Code
Phone Number
Email
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