Vaia Funeral Home Our Services Arrangements Casket Selection Our Staff Send Sympathy  

The following information is required for the obituary and by
The Pennsylvania Department of Vital Records
before they will issue a Certified Death Certificate. 

Please fill out as much or as little of this information as you wish, and submit to us.  Your information will remain confidential and placed in a secure file for future use.

Arrangements Information Sheet

Personal Information

Name       SS#

Address     City    State    Zip

Phone #   City/Boro/Township of    County

Martial Status   Spouses Name Is your Spouse

Previous Address

 Date of Birth    Age   City/County of Birth

Male  Female     Race     If Other Specify 

Citizenship Country       Education

Occupation/Former Occupation   Type of Business/Industry

Military Branch                                  Did you Serve in  

If Wartime, What War?                           Is Your DD214 Available? 

Father's Name      Living    Deceased

Mother's Name    Maiden Name   Living Deceased

_____________________

 

Survivor Information

Children's Information:   Number of Sons    Number of Daughters 

Child #1      Name   Spouse's Name

City and State
 

Child #2       Name   Spouse's Name

City and State
 

Child #3      Name   Spouse's Name

City and State
 

Child #4      Name   Spouse's Name

City and State
 

Child #5      Name   Spouse's Name

City and State

_____________________

 

Sibling Information:   Number of Brothers    Number of Sisters

Please add names below only if you wish them listed individually in your obituary.

Sibling #1      Name   Spouse's Name

City and State
 

Sibling #2       Name   Spouse's Name

City and State
 

Sibling #3      Name   Spouse's Name

City and State
 

Sibling#4      Name   Spouse's Name

City and State
 

Sibling #5      Name   Spouse's Name

City and State

_____________________

 

Grandchildren Information:  Number of Grandchildren

Please add names only if you wish them listed individually in your obituary.

_____________________

 

Great Grandchildren Information:  Number of Great Grandchildren

Please add names only if you wish them listed individually in your obituary.

_____________________

 

Niece and Nephew Information:  Number of Nieces   Number of Nephews

Please add names only if you wish them listed individually in your obituary.

_____________________

 

Non-Family Loved Ones

     Please list any others you wish mentioned in your obituary

_____________________

 

Pre-Deceased Information: 
Please add names only if you wish them listed individually in your obituary.

Relationship      Name  

Relationship      Name  

Relationship      Name  

Relationship      Name  

Relationship      Name  

_____________________

Other Information

Religious Preference?    Clergy's Name

Your Church     City/Town

 

Please List The Organizations of which you are a Member

  List this in your Obituary?  

  List this in your Obituary?  

  List this in your Obituary?  

_____________________

 

Do you Wish Contributions sent in your name to any Organization/Foundation.  If yes Please List

  List this in your Obituary?  

  List this in your Obituary?  

_____________________

 

Please list the newspapers you wish your obituary placed in

1.      2.

_____________________

 

How many Copies of Certified Death Certificates will you need? 

Please be Aware that your estate will need one for each bank account, certificate or asset in your name.  The State of Pennsylvania Currently Charges $6.00 each for a Death Certificate.  Additional Death
Certificates can be ordered at a later date, but the State charges $9.00 each and may take 6 to 8 weeks

_____________________

 

Please add any additional comments or instructions below

 

Do you wish a follow up phone call for any reason

If yes, Please give us your phone number   The best time to call is?

 

If you are completing this Information for another, please complete below

Informants Name:             Informants Relationship

Informants Address:     Informants Phone #:

 

Thank you for trusting us to assist you in your funeral arrangements.  By taking this step now, you are assuring that these decisions will not have to be made at a very difficult and trying time in your loved ones' lives