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Infant Burial Assistance Request
Some information requested is optional and used for statistical purposes only to help us meet the needs of families better.
Preferred Language
English
Spanish
Other
Infant's Full Name
*
First Name
Last Name
Infant's Birthday
*
-
Month
-
Day
Year
Date
Day of Infant's Death
*
-
Month
-
Day
Year
Date
If pregnancy related, how many weeks in your pregnancy were you?
Cause of Death (statistical purposes only)
Prematurity/Complication related to Prematurity
Life Limiting Prenatal Diagnosis (birth defect, genetic)
Stillborn
Sudden Infant Death Syndrome (SIDS)
Medical Diagnosis (ie. RSV, infection)
Accidental Death (ie MVA, drowning, trauma injury)
Other
Infant's Ethnicity (statistical purpose only)
African American
Asian
Caucasian
Hispanic
Native American
Other
Parent 1
*
Please Select
Mother
Father
Mother's Full Name
*
First Name
Last Name
Mother's Marital Status (statistical purpose only)
Single
Married
Widow
Other
Mother's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Email
example@example.com
Parent 2
Please Select
Mother
Father
Father's Full Name
*
First Name
Last Name
Father's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Email
example@example.com
Household Income (statistical purposes only)
$0-$30,000
$30,000-$60,000
$60,000-$90,000
$90,000-$120,000
>$120,000
Mortuary Name
*
Mortuary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mortuary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you met with the Mortuary?
*
Yes
No
Services Selected
Burial
Cremation
Undecided
Final Mortuary Estimate
Check that all that applies:
Please add my baby to the virtual Butterfly Remembrance Garden on the Luna Babies Foundation website (only baby's first name and date of birth will be noted)
I would like to stay connected to the Luna Babies Foundation community and receive email updates on upcoming events and outreach.
Please add me to the Luna Babies Foundation Facebook Group to connect with other families going through a pregnancy and/or infant loss. (If now is not the right time, you can follow us on social media and join when you are ready)
I would like help connecting with local grief support and resources- the Luna Babies Foundation will contact you via the primary phone number provided above
Parent Completing this Form
*
First Name
Last Name
Submit
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