To officially register with the Cremation Society of NEPA, complete this form and submit it by clicking on the "Register" button. This information is legally required to complete a Pennsylvania death certificate and is kept strictly confidential.
Please choose what you would like information on: Direct Cremation Package Veterans Package Memorial Service
Full Name (First, Middle, Last) :
Legal Address (Street Address):
City: State: Zip Code:
County: Township:
Gender: Male Female Date of Birth:
City of Birth: State/Country of Birth:
Social Security Number (SSN):
Education (Years completed):
Ancestry: Race:
Marital Status: Married Never Married Widowed Divorced Veteran: Yes No
Occupation (Present or Before Retirement):
Employer:
Name of Spouse (First, Last/Maiden): Deceased: Yes No
Name of Father (First, Last): Deceased: Yes No
Name of Mother (First, Last): Deceased: Yes No
Next of kin: Telephone#:
Address:
Cemetery Name:
Cemetery Address:
Physicians Name: Telephone:
Physicians Address:
Other instructions for final arrangements:
