ABOUT US
OBITUARIES
SERVICES
PLANNING AHEAD
GRIEF SUPPORT
RESOURCES

ABOUT US
OBITUARIES
SERVICES
PLANNING AHEAD
GRIEF SUPPORT
RESOURCES

Resources

If a Death Has Just Occurred

Death Certificate Pre-Arrangement Form

Free Text

Decedent's Primary Information

Full Name (List any AKA's if applicable*

Father's Full Name*

Last Address (Including City, State, Zip)*

Birthplace (City, State)

Mother's Full Name (Maiden)

Marital Status

Date of Birth*

Gender*

Age

Social Security Number*

Free Text

Decedent's Work / Education History

Decedent's Highest Level of Education

Decedent's Usual Occupation (i.e. Mechanic)

Type of Industry (i.e. Automotive)

Free Text

Decedent's Race / Ethnicity

Hispanic Origin

Primary Race of Decedent

Tertiary Race of Decedent

If Hispanic, please specify

Secondary Race of Decedent

Please Specify if indicated

Free Text

Death Information

Date of Death

Location of Death

Address (Including City, State, Zip)

Time of Death

Name of Facility (if applicable)

Attending Doctor / Phone Number

Military Record

Military Record

Did the decedent serve in the military?

Yes

No

Unknown

Branch of Service

Service/Serial Number

If yes, would you like military honors?

Yes

No

Maybe, please explain

Date of Entry

Rank of Discharge

Do you have a copy of the DD-214?

Yes

No

Not Sure

Date of Discharge

War(s) Fought In

Free Text

Please EMAIL and send DD-214 / Discharge form if able.

Free Text

Informant's Information (Next of Kin)

Full Name

Address (Including City, State, Zip)

Primary Phone Number

Relationship to Deceased

Email Address

Secondary Phone Number

Free Text

Additional Points of Contact

Name

Relationship

Phone Number

Email Address

Name

Relationship

Phone Number

Email Address

Free Text

Final Disposition

Type of Service

Location of Service

Do you have a plot?

Date of Service

Cemetery

Is there a headstone currently?

Would you like the funeral home's help with any of the following? (Check all that apply)

Obituary

Flowers

Programs

Video Tribute

Audio Recording

Prayer Cards

Other (Please specify)

Please include any Questions, Instructions, or Special Requests below

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