Funeral Service Request Form
Note: Intake funeral service request is only provisionary. All arrangements will be confirmed by the Bereavement Ministry.
Name Of Deceased
First Name
Last Name
Address of Deceased
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Age
Date of Death
-
Month
-
Day
Year
Date
Next of Kin
Full Name
Relationship
Next of Kin Contact Info:
Contact Number
Email
Parishioner
Yes
No
Type of Funeral (if known)
Funeral Mass with Cremains
Funeral Service with Casket
Graveside Only
Approximate # Attending
Immediate Burial following the funeral service?
Yes
No
Services Contact Information:
Name of Caller:
Caller's Full Name
Relationship to Deceased
Phone Number
Email Address
Full Address
Parishioner
Yes
No
If No, please indicate Parish, City/State
Potential Dates and Times for Service (if known). Dates and times are not guaranteed and will be be confirmed by our Staff
*
Church Availability
Yes
No
Do you want your loved one's name included in:
*
Bulletin
Website
November Memorial Mass
Bereavement Minister:
Name
Remarks:
Office Use Only
Taken by:
Name
Date
Print
Submit
Should be Empty: