Legal InformationName* First Last SexMaleFemaleDate of Birth Date Format: MM slash DD slash YYYY Place of BirthResidence (of decedent)Name of FacilityAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital StatusNever MarriedMarriedWidowedDivorcedSeparatedSurviving Spouse (if wife, maiden name)RaceWhite/CaucasianAsianBlack or African AmericanCheck the box that best describes your raceEducation8th Grade9th-2th grade, no diplomaHigh school graduate or GED4Some college credit, but no degreeAssociate's degreeBachelor's degreeMaster's degreeDoctorate or Professional degreeVeteran InformationDid you ever serve in the armed forces?YesNoWhat Branch of Service?OccupationMost Recent OccupationPlace of Employment (last or longest)Type of Business or IndustryParentsName of FatherMaiden Name of MotherInformant of Next of Kinsurviving spouse or person in charge of arrangementsRelationship to DeceasedName* First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Simple Cremation Price: $985.00 Crematory Selection*White Haven Memorial Park Crematory This iframe contains the logic required to handle Ajax powered Gravity Forms.
