Online Vital Statistics Form

Vital Statistics Needed for Death Certificate

If you have any questions while filling out the form please feel free to give us a call at 724-887-7110.

Deceased's Full Legal Name

Gender

Male

Female

Social Security Number

Date of Birth

Birthplace

Free Text

Residence

Street and Number

Township

City/Borough

Zip Code

Country

Was Deceased a Veteran?

Yes

Marital Status

Spouse's Name

Father's Name

Mother's Full Name

Highest Level of Education Completed

Decedent's Race

Usual Occupation

Type of Business of Industry

Name of Cemetery

Informant's Full Name

Informant's Address

Informant's Phone Number

Relationship to Decedent

Address: