Address: 602 Birch Street, Scranton, PA, 18505, US
Telephone: (570) 343-0413

Please fill out this form with the information required to complete the Pennsylvania Death Certificate.

Contact Person
Information about you.
First Name
Middle Name
Last Name
Address*
Street Address City State ZIP Code
Email
Phone*
Cell Phone
Work Phone
Relationship to Deceased*
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Deceased Person Information
Information about the deceased.
First Name
Middle Name
Last Name
Date of Birth*
DD slash MM slash YYYY
Birthplace: City, State, Country*
Race
Sex*
Marital Status*
Name of Spouse (maiden name, if wife)
In Armed Forces*
- Yes
- No
Social Security Number*
Usual Occupation*

Can not used RETIRED. Please put the job the deceased did most their life.
Kind of Business/Industry*
Education (highest completed) Elementary & Primary (0-12)*
Higher Education*
Address*
Street Address City State ZIP Code
Father
First Name
Middle Name
Last Name
Mother
First Name
Middle Name
Last Name
Maiden (last) Name*

Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Did the deceased live in a township?*
- Yes
- No
Name of Township
Deceased's County of Residence
Place of Death
Date of Death
MM slash DD slash YYYY
Primary Care / Family Doctor
Doctor's Address
Street Address City State ZIP Code
Doctor's Phone

Death Cert Info

Contact Person