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At Need Form

We are very sorry for your loss and stand ready to assist you in your time of need. If you have not already scheduled a meeting with us, please call us.

If you prefer, you are welcome to send us information using the form below. We understand that you may not have access to all of the details below (or would prefer to provide in person). You are welcome to fill out as much or as little as you prefer. We will cover the remainder when we meet with you.

Arrangement Information

Personal Information of Deceased

Last Name

First Name

Middle Name

Date of Birth

Place of BirthCity and state

Social Security Number

Decedents Race

Decedent of Hispanic or Haitian Origin?

YesNo

If yes to above please select an option

Marital Status

Name of spouseIf married

Occupation

Retired

YesNo

Decedent's Education

Date of Death

Place of Death

Name of FacilityNursing home, hospital, group home, etc.

City, Town, Or Location of Death

Decedent's Address

Street

City

State/Province

ZIP/Postcode

Preparation Information

Has a Doctor / Coroner Been Notified?

YesNo

If deceased passed at home

Has the Body Been Released for Removal?

YesNo

Do You Permit Us to Embalm the Body?

YesNo

For traditional funeral service or cremation with viewing service

Do You Permit Us to Cremate the Body?

YesNo

For direct cremations, cremations with memorial or viewing with cremation service

If Yes, Who Has Granted Permission?

Was decedent ever in U.S. Armed Forces

YesNo

Military

Military Branch

Parental Information

Father's NameFirst, Middle, Last, Suffix

Mother's NameFirst, Middle, Maiden (Last name prior to marriage)

Personal Information of Person Legally Responsible for Disposition

Last Name

First Name

Middle Name

Relationship to Deceased

Street

City

State/Province

ZIP/Postcode

Primary Phone Number

Best Time to ReachVia phone

Secondary Phone Number

Email Address

Type of service

Funeral expenses source

Number of Death Certificates requesting$10.00 per copy

Do You Have a Prearrangement on File with Us?

YesNo

If Yes, Under What Name?

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