Form 47 Pa PDF Details

In the state of Pennsylvania, there are a few specific forms that must be completed in order to change your name. The first form, which is titled "Application for Correction of Name" or Form 47 Pa, must be filed with the Office of Vital Records. This form is used to request a change to your name due to marriage, divorce, or other legal proceedings. The second form, " Request for Change of Name - Civil Action" or Form 603, is used if you would like to change your name without any legal proceedings. This form must be filed with the Prothonotary's office in the county where you reside. For more information on changing your name in Pennsylvania, please review the following links: Form 47 Pa: https://www.health.pa.gov/Documents/forms%20and%20publications/VitalRecords/ApplicationforCorrectionofName47PAENG1-17pdf.pdf Form 603: https://www.pacourts.us/assets/opinions_courtfiles_PDFs/3PSC0603199AOOPINION favorable Court of Common PleasMontgomery County .pdf?cb=22148&rc=2&wc=MQucGtuz4b%252B

QuestionAnswer
Form NameForm 47 Pa
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespa 47, form 47 pa, pa 47 form, pa form 47pa

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INVESTORS HERITAGE Life Insurance Company

200 CapitalAvenue • PO Box 717 • Frankfort, Kentucky 40602-0717

TollFree(800)422-2011 • Fax:(502)223-6575

PEN N SY LV AN I A

FUNERAL DI RECTOR’S STATEMENT

( Use ON LY for N on - Con t e st a ble Pr e n e e d Cla im s)

INSTRUCTIONS: Mail completed form with the Policy and Obituary (Newpaper Clipping).

Name of Deceased

 

 

 

Social Security Number

 

 

Deceased was

 

 

 

 

 

 

 

 

 

 

 

 

Male

Fem ale

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (P.O. Box - No. - Street)

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number(s)

 

Issue Date of Policy(ies)

 

 

Type of Policy(ies)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Life Insurance

Annuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Life Insurance

Annuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

Place of Birth:

 

 

 

Date of Death:

 

Place of Death:

 

____/____/______

___________________________

 

____/____/______

 

_____________________________

(Month / Day / Year)

(City and State)

 

(Month / Day / Year)

 

 

 

(City and State)

PRIMARY CAUSE OF DEATH as listed on the death certificate filed with the Bureau of Vital Statistics

Where did death occur?

Hospital

Nursing Home

Residence

Other: ________________________

(PLEASE CHECK ONE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Arranging Funeral

 

Relationship to Deceased

 

Social Security Number

 

 

 

 

 

 

 

 

 

Address (P.O. Box - No. Street)

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

Telephone Number

 

Were the Policy Proceeds Assigned?

Is the Newspaper Obituary Attached?

(

)

 

 

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

I he r e by ce r t ify t ha t I a m a n a ut hor ize d, lice nse d Fune r a l D ir e ct or ; t ha t t he a bove na m e d I nsur e d is de ce a se d a s se t for t h a bove ; t h a t I w ill/ h a ve pr e pa r e ( d) for fin a l disposit ion t h e body of t h e a bove na m e d pe r son; a nd t ha t I w ill/ ha ve fully pe r for m ( e d) t he fune r a l se r vice s for t he a bove na m e d pe r - son . I hereby cert ify t hat all inform at ion above is t rue and correct t o t he best of m y knowledge and belief. I underst and t hat t he life insurance policy is not cont est able because it was guarant eed issue or because it has been in effect for t wo ( 2) years from t he dat e of issue. The Obit uary ( newspaper clipping) , t he Cert ificat e of Perform ance, if required by st at e law, and t he policy should accom pany t his form . I nvest ors Herit age reserves t he right t o request addit ional inform at ion which it , in it s sole discret ion, deem s necessary t o adj udicat e a claim .

An y pe r son w h o k n ow in gly a n d w it h t h e in t e n t t o de fr a u d a n y in su r a n ce com pa n y or ot h e r pe r son files an applicat ion for insurance or set t lem ent of claim cont aining any m at erially false inform at ion or conce a ls for t he pur pose of m isle a ding, infor m a t ion conce r ning a ny fa ct m a t e r ia l t he r e t o com m it s a fr a udule nt a ct , w hich is a cr im e a nd subj e ct s such pe r son t o cr im ina l a nd civil pe na lt ie s.

Name and Address

Signature of Funeral Director

Funeral Director License No.

 

 

 

 

Telephone Number

Email Address

 

(

)

 

 

 

 

 

Tax I.D. Number

Date

 

 

 

 

For m 47 PA Rev. 6/ 2006

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