Last Name *
First Name *
Address 1 *
Address 2
City *
State *
Zipcode *
E-mail
Phone (xxx-xxx-xxxx) *
Township or Borough
   
Single Married Widowed Divorced
Spouse's Name:
Date of Birth (mm/dd/yyyy)
Place of Birth (Town and State)
Father's Last Name First Name
Mother's Maiden Name First Name
Length of Residence to above address
Previous Addresses and Length of Residence  
 
Social Security Number
Occupation (or Retired from)
Location
Last Employer
Type of Business
How Long Employed
Job Description
Other Employers  
 
Church Membership
Schools Attended  
 
Organizations or Memberships, Years, and Place  
 
Military Service  
Branch
Serial Num
Date Entered Place
Date Discharged Place
Rank/Rating
Wars/Conflicts Served
Awards or Medals
Veteran of
   
Wedding Anniversary
Relation Survivors Address
Number of Grandchildren
Number of Great Grandchildren
   
Name of Cemetery
Location of Cemetery
Lot #
 		Section
Grave #
   
Newspapers to be notified  
Lancaster Reading Picture to be in Paper
Others
   
Pall Bearers