Guss Funeral Home, Inc.
20 South Third Street
Mifflintown, PA 17059
Tel: 1-717-436-2149


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At Need
Information about the deceased
Last Name
First Name
Middle Name
Maiden Name
Sex
Father's Name: First  Middle   Last 
Mother's Name: First  Middle   Last 
Mother's Maiden Name
RaceAfrican-American

Caucasian

Native American

Hispanic

Asian

 Country of origin 
Date of birth
City of birth  State 
OR Country if not USA
Date of death
City of death
State of Death
County of death
Location of death   Location (if other) 
Name of the place of death
Social Security Number
Education   
Usual occupation
(most of life)
Type of business
Company
(optional)
Marital status
Surviving Spouse
If wife, enter maiden name
Surviving spouse address
City/Town  State   ZIP 
Mother's full name
Father's full name
Type of disposition
Disposition will be
If cremation, disposition of ashes
Preparation and viewing
Viewing/embalming preference
I authorize Guss Funeral Home, Inc. to embalm
Name of authorizing person
Relationship to deceased
Veteran information
Was the decendent ever in the US Armed Forces?Yes No   If no, continue to the next section
Branch of service
Date enlisted
Date discharged
Honorable dischargeYes No
Service/Serial number
Copy of discharge papers is availableYes No
Informant information
Name of person in charge
Relationship to deceased
Address
City  State   ZIP 
Home Telephone
Cell phone
Email
Funeral/memorial service information
Preferred place of service
Religious denomination
Is there pre-need funeral insurance on decedent?Yes No
If yes, specify type
Memorials & donation preferences
 Please list memorials or charitable donations that you'd like listed in the obituary 
Special instructions
 Optionally use the area below to provide additional information or instructions to us. 
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