Plan Online 2 (Simple Choices) (At-Need Form)

Contact Information

Your Name*:

Your Telephone Number*:

Your Email *:

Will You be Responsible for Making the Arrangements?*:

YES - I will be making the arrangements NO - Someone else will be making the arrangements (specify who)

Who is this Plan for?

Name of Deceased :

Your Relation to this Person?*:

My Spouse My Domestic Partner My Parent My Child My Sibling My Grandparent My Close Friend or Other Relative (specify)

Vital Information

Gender:

Male Female

Date of Birth:

City and State of Birth :

Age:

Race / Ethnicity :

White/Caucasian Black or African American American Indian (Specify) Alaskan Native Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (Specify) Other (Specify) One or More Races (Please Specify/List) Unknown

Hispanic Origin ( Y / N ):

NO - NOT CONSIDERED Spanish/Hispanic/Latino(a) Yes, Puerto Rican Yes, Mexican, Mexican American, Chicano Yes, Cuban Yes, OTHER Spanish/Hispanic/Latino(a) (specify) UNKNOWN

Social Security Number:

Deceased's Legal Residence (No PO Boxes)

(Full Street Address, City, State, Zip):

Deceased's Education

Highest Level of Education Completed:

8th Grade or Less 9-12th (No Diploma) HS Graduate or GED Some College, But No Degree Associate's Degree Bachelor's Degree Master's Degree Doctorate or Professional Degree

Deceased's Occupation / Employer (before retirement)

 

*DO NOT ENTER RETIRED*

Please Specify Occupation Prior to Retirement

Usual Occupation (Job Title / Description):

Employer / Company Name & Location?:

Was the Deceased a Veteran?

Military Veteran ( Y / N ):

NO YES - Army YES - Air Force YES - Navy YES - Marine Corps. YES - Coast Guard YES - Space Force

Please Specify Years Served or War Time Period:

Do You Have a Copy of the DD-214 / Honorable Discharge?:

YES - I will supply a copy NO - Please Help me obtain a copy

Please Upload DD-214 / Honorable Discharge:

Deceased's Marital Status

Legal Marital Status:

Never Married Married Widowed Divorced Separated

 

Please Include Spouse's Maiden Name

(Prior to Marriage)

Surviving Spouse :

Parents

Birth Name of Father/Parent:

 

Please Include Mother's Maiden Name

(Prior to Marriage)

Birth Name of Mother/Parent:

INFORMANT's INFO (Next of Kin or Agent in Charge of Services)

Informant's Name *:

Informant's Mailing Address*:

Informant's Telephone *:

Informant's Email :

Desired Services

Specify the Services You Desire From Us*:

Simple Cremation (No Service, No Viewing) with Return of the Ashes Simple Cremation (No Service) But with a Private, Family-Only Viewing, Before Cremation in our Bereavement Suite Simple Cremation (No Service) But with Attendance/Witness of the Cremation at the Crematory Simple Cremation with Cemetery Placement by our Staff (No Services/Witness/Attendance at the Cemetery) Simple Cremation with Cemetery Placement by our Staff & Graveside/Nicheside Services Cremation with a Memorial Service at our Funeral Home (or another location with our funeral directors, staff, vehicle(s) and equipment) Cremation with a Funeral and a Viewing at our Funeral Home (or another location, with our funeral directors, staff, vehicles, equipment and cremation casket)

Ordering Death Certificates

How Many Death Certificates Do You Wish To Order?:

Information about the Deceased

What is the Deceased's Estimated Weight?*:

Does the Deceased Have a Pacemaker or a Battery Powered Device Impanted?*:

Does the Deceased Have Any Jewelry or Personal Effects to be Returned?*: