Pennsylvania USGenWeb Archives Archives

Record Submission Forms

***NOTE***
These forms are for genealogical and historical records only.
DO NOT ENTER ANY INFORMATION ON LIVING INDIVIDUALS.
Please transcribe the full record, if you do not have the full record or all the facts required, please do not use this form.
Please cite the source of your information in the Additional Comments box if there is no box on the form for citing a printed source.
(Please use the obituary form for Obituaries or Death Notices)
Pennsylvania USGenWeb Archives Death Certificates
Click here for information about these forms. (Opens a New Browser)
Use this form to automatically transcribe and send your death certificats to the Pennsylvania USGenWeb Archives
formatted for acceptance in the USGenWeb Archives Project. Or you can send your file by email to the
Archives Manager for your county (Addresses below)
An asterisk {*} next to a field means it is required, please double check before submitting.
Your tab key will work to move between the fields.

Your Email Address:	*
Your First Name-Submitter:	*	Your Last Name-Submitter:	*

Deceased Name (First, Middle)

Deceased Last Name

Date Of Death:
Month:	Day:	Year:*
Time Of Death

Place Of Death
Gender:		Race
Age:
Place Of Residence:
Marital Status

Spouses Name (First, Middle)

Spouses Last Name

Date Of Birth:
Month:	Day:	Year:

Place Of Birth:
Cause Of Death:
Hospital:
Social Security Number:
Occupation:

Mothers Name (First Middle)

Mothers Maiden Name

Mother's Place Of Birth:

Fathers Name (First Middle)

Fathers Last Name

Father's Place Of Birth

Funeral Home/Undertaker
Doctor
Coroner
Informant
Date Of Burial:	Month:	Day:	Year:
Place Of Burial
Date Recorded:	Month:	Day:	Year:

Source Of Record: *

Certificate No:

Other Information On Record:
Enter Any Additional Comments:

**County or Counties Where File is to be Posted:**
*Required*

If you want a copy of this sent to your email check here:

(Before you submit please note, we can not provide you with records, if you are looking for a record please click here.
These forms are for sharing records which you already have in your possession.)

USGenWeb Archives State File Manager: Mary Ann Lubinsky

USGenWeb Archives	PAGenWeb Project	USGenWeb Project

Record Submission Forms For Other States
Record Submission Forms For Other States Mirror Site

Problems or Comments about these forms contact Debra Crosby
Created by David Crosby � Copyright 2002 - Present