Information About Your Loved One
Decedent's Personal Information
Full Name
First Name
Middle Name
Last Name
Date of Birth
*
Date of Death
*
Age
*
Exactly how old was your loved one when he/she passed
Time of Passing
If you know the exact time of death type it here
Approx Weight
*
Your Loved one's Date of Birth
Approx Height
*
Your Loved one's Date of Birth
Sex
Please Select
Male
Female
Address where he/she lived
Street Address
City
State / Province
Postal / Zip Code
Place of Death
Home/Hospital/Nursing Home/Away from Home/on the street/etc
Address if known (if home then put 'Same as above')
City
State / Province
Postal / Zip Code
Decedent's Place of Birth
Decedent's Marital Status
County Number of Years in County
County in which he/she passed
Father of the Decedent's Name and place of Birth
Mother of the Decedent's Name and Maiden Name and place of Birth
Informant's Phone Number
Informant's E-mail
example@example.com
Informant's Address
Street Address
Relationship to Deceased
City
State / Province
Postal / Zip Code
More Details
Was Deceased a Veteran? If so please provide Branch of Service and other details
Please provide Military Discharge Paperwork (DD214) at time of appointment
When Deceased worked what was their occupation, how many years, and for whom did they work.
Highest Level of Education
Ex: elementary school, High School Grad, AA, BA, MA
Funeral services you wish to discuss at your Appointment
Examples: Direct Cremation, Viewing Service with Cremation to follow, Services with a Burial, Traditional Catholic Services
Any additional important information that we should know
Date
-
Month
-
Day
Year
Date
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