Online Information Form

Below is all of the required information to complete funeral documents. Please complete as much of the form as you can and if you do not have all of the information, don't be concerned as we will follow up with you about any missing information.  

Most people find this form very convenient but if you feel more comfortable providing this information over the phone or in person, please contact us at 1-877-372-2742.

The death has occurred I am planning in advance

Informant's Information

Please enter the information of the person filling out this form.

Relationship to Deceased
First name
Middle name
Last name
Street Address
City
Zip Code
Phone
E-mail

Next of Kin/Executor Information

Is there a will?	Yes No Unsure
In order to make final arrangements we will require the executor's participation and permission.
Is the above person the executor of the will?	Yes No
Is the above person the legal next of kin?	Yes No
Please enter the information of the executor below:		Please enter the information of the legal next of kin below:
Relationship to Deceased
First name
Middle name
Last name
Street Address
City
Zip Code
Phone
E-mail

Deceased's Information

Location of Deceased
First name
Middle name
Last name
Birth Information
Date of Birth
City of Birth
State of Birth
Country of Birth
Social Security Number
Marital Information
Marital Status	-- Please select -- Single Married Widowed Divorced Common-Law Same-Sex Partner
Spouse's First Name
Spouse's Middle Name
Spouse's Maiden Name
Armed Forces
Has this person ever served in the armed forces?	Yes No
What branch of service?	-- Please select -- Army Air Force Navy Marines
Do you have a copy of their discharge papers (DD214)?	Yes No
Residence Information
StreetAddress
City
State
Zip Code
Is this in the City Limits?	Yes No
Parent Information
Father's First Name
Father's Middle Name (optional)
Father's Last Name
Mother's First Name
Mother's Middle Name (optional)
Mother's Last Name
Demographics
Education	-- Please select -- 8th Grade or less 9th - 12th Grade, no diploma High school grad or GED College, no degree Associate Degree Bachelor Degree Master Degree Doctorate Unknown
Hispanic Origin	Yes No -- Please select -- Mexican Cuban Puerto Rican Other
Race (specify if necessary)	-- Please select -- White Black/African American Asian Indian Chinese Filipino Vietnamese Japanese Korean Hawaiian Samoan Guamanian American Indian/Alaskan Native (specify Tribe) Other Asian (specify) Other Pacific Islander (specify) Other (specify)
Occupation Information
Occupation for most of working life
Industry
Safety Information
Is there a pacemaker or defibrillator present?	Yes No Unsure
Permission granted to remove said device?	Yes No
Was death due to infectious, or contagious disease?	Yes No
Please specify

Services

Cremation Burial Undecided
Would you like more information, or to have us organize, one of the following services?	I do not wish to organize a service 1 hour family gathering more info A family gathering of up to 25 attendees and held at any of our pre-designated locations with an urn present. Flowers, catering, and other services can be arranged. Memorial Service more info A 2 hour visitation incorporating a brief formal or ritual service if desired with an urn present. Our staff can arrange for everything, including flowers and catering if desired. Visitation and Reception more info A 2 hour visitation followed by a service and ceremony. Families also have the option of a graveside service after the ceremony as well as a reception if necessary. Identification more info Being able to see a loved one before a final disposition is helpful for a sense of closure. This is not necessarily a funeral service, but an opportunity to briefly say goodbye for before final disposition. Witnessing of cremation more info Witnessing of a cremation is a service where families wish to witness the actual cremation process. This is a very common request since this type of brief ceremony provides families and friends with a feeling of closure.
Would you like help settling your estate?	Yes No
Are there any additional services you are considering?	Yes No
Please specify
Additional Notes
How did you find out about our services? (Specify if possible)	Internet Brochure Friend/Family Hospital/Nursing Home Billboard Newspaper Article L-Train Ad	Radio Ad Bus Ad Bus Shelter Ad TV Commercial TV Interview Other
Verification Options	Please Verify by Phone Please Verify by Email
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