Guss Funeral Home, Inc.
20 South Third Street
Mifflintown, PA 17059
Tel: 1-717-436-2149
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Information about the deceased
Last Name
First Name
Middle Name
Maiden Name
Sex
Choose
Male
Female
Father's Name: First
Middle
Last
Mother's Name: First
Middle
Last
Mother's Maiden Name
Race
African-American
Caucasian
Native American
Hispanic
Asian
Country of origin
Date of birth
City of birth
State
--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
OR Country if not USA
Date of death
City of death
State of Death
--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
County of death
Location of death
Select
Home
Emergency Room
Hospital
Nursing Home
In transport
Other
Location (if other)
Name of the place of death
Social Security Number
Education
Primary
0
1
2
3
4
5
6
7
8
9
10
11
12
College
0
1
2
3
4
5+
Usual occupation
(most of life)
Type of business
Company
(optional)
Marital status
Choose
Married
Never Married
Divorced
Widowed
Surviving Spouse
If wife, enter maiden name
Surviving spouse address
City/Town
State
--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
ZIP
Mother's full name
Father's full name
Type of disposition
Disposition will be
Choose
Earth Burial
Mausoleum Entombment
Cremation
Ship Out of Area
Not sure
If cremation, disposition of ashes
Choose
Cemetery Burial or niche wall
Scatter
Take home
Other
Not sure
Preparation and viewing
Viewing/embalming preference
Choose
Viewing/visitation
One-time viewing for immediate family
Use option required by type of disposition
No viewing/embalming
Not sure
I authorize Guss Funeral Home, Inc. to embalm
Choose
Yes
No
Will advise
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 discharge
Yes
No
Service/Serial number
Copy of discharge papers is available
Yes
No
Informant information
Name of person in charge
Relationship to deceased
Address
City
State
--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
ZIP
Home Telephone
Cell phone
Email
Funeral/memorial service information
Preferred place of service
Choose
Funeral Home
Church
Other
Will advise
Religious denomination
Is there pre-need funeral insurance on decedent?
Yes
No
If yes, specify type
Memorials & donation preferences
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Special instructions
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