Select Type of Arrangement Needed*

Loved one has passed (Immediate Need)
Pre-Plan for the future (Keep my Information on File)
Pre-Fund for the future (Open a Revocable or Irrevocable Trust)

Service Types*

Simple Cremation
Simple Cremation with a Graveside Service
Simple Cremation with a Final Goodbye

Date of Death*

Place of Death (Facility or Residential Address)*

Legal Information (of Decedent)

Name*

First Middle Last Suffix

Sex

Male
Female

Date of Birth

Age

Place of Birth*

City State / Province / Region Country

Veteran Information

Did your loved one ever serve in the armed forces?*

Yes
No

What Branch of Service?*

Hispanic Origin / Race / Education / Marital Status

Hispanic Origin

(Check the box that applies)

No, Not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, Cuban

Race

(Check the box that best describes your race)

White/Caucasian
Asian
Black or African American

Education

(Check the box that best describes the highest degree or level of school completed)

8th grade
9th-12th grade, no diploma
High school graduate or GED
Some college credit, but no degree
Associate’s degree
Bachelor’s degree
Master’s degree
Doctorate or Professional degree

Marital Status

Surviving Spouse

(If wife, First and Last maiden name)

Occupation

Most Recent Occupation

(Do not enter retired)

Place of Employment

(Last or longest)

Type of Business or Industry

Locality of Employment

City State

Current Address/Residence (of Decedent)

Name of Facility

(If not facility, give address)

Name of Facility*

(If not facility, give address)

Address*

Street Address City State ZIP Code

Parents

Name of Father

First Last

Maiden Name of Mother

First Last Maiden Name

Informant/Next of Kin

(Surviving spouse or person in charge of arrangements)

Name*

First Last

Relationship to Deceased*

Address*

Street Address City State ZIP Code

Email*

Phone*

Person Completing this Form

Name*

First Last

Relationship to Deceased*

Address*

Street Address City State ZIP Code

Email*

Phone*

Additional Comments or Questions

Enter Comments or Questions

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Phone

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Start Planning

Legal Information (of Decedent)

Veteran Information

Hispanic Origin / Race / Education / Marital Status

Occupation

Current Address/Residence (of Decedent)

Parents

Informant/Next of Kin

Person Completing this Form

Additional Comments or Questions

Henrietta

(585) 359-2300

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