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 Date Format: 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 NameMiddle NameLast NameSocial Security NumberPhone numberCell Phone (if applicable)Email Legal Residence Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Boro or Twp of ResidenceCounty of ResidenceDate of Birth Date Format: MM slash DD slash YYYY Birthplace: (City)Birthplace: (State)Birthplace: (County)Birthplace: (Country)U.S. CitizenYesNoSexMaleFemaleRaceCaucasianAfrican AmericanHispanicAsianOtherMarital Status as of This DateMarriedNever MarriedWidowedDivorcedName of Spouse (maiden name, if wife)check if spouse is deceasedIn Armed ForcesYesNoNot SureDischarge 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 OccupationWhile many people have had many different occupations throughout their career, please choose the one that best represents the individual.Kind of Business/Industryi.e. manufacturing, retail, medical, laborer, etcEducation (highest completed) Elementary & Primary (0-12)123456789101112Higher EducationNoneSome College CreditAssociates DegreeBachelors DegreeMasters DegreeDoctorate/Professional DegreeNote: Higher education does NOT include technical, trade, or business schools.Father's First NameLegal 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 NameLegal 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 NameLegal 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 deceasedMother's First NameLegal 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 NameLegal 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 NameLegal 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) NameLegal 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 deceasedPlease Check One of the Following OptionsCasket BurialCremationBody DonationNot Sure YetFamily InformationChildren (oldest to youngest with spouse info and phone number)If children are deceased, please type "deceased" before the respective name.First (Spouse) Last. Phone NumberExample: Mike (Sally) Jones. (717) 555-5555Additional Notesplease provide us with any other information that you feel is pertinent.Additional Notes (optional)Person Completing This FormI am Completing This Form For:MyselfMy Spouse/PartnerMy Parent/In-LawIf choosing an option other than "myself" please provide your contact information below.Legal Name First Last Legal Residence Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail CAPTCHA
