Endswell Intake Form
This form is used to collect information and build a case file so we have everything we need when we're notified that death has occurred. Please call or email us if you have any questions.
Are you completing this form for yourself or someone else?
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FOR MYSELF
FOR SOMEONE ELSE
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Contact Details
Email of Individual Completing Form
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If you are filling out this form for someone else, please provide your name, email, phone number, and address, as well as your relationship to the individual for whom these arrangements are being made.
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First Name
Last Name
Phone Number of Individual Completing Form
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Please enter a valid phone number.
Format: (000) 000-0000.
Address of Individual Completing Form
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to the individual for whom the funeral service is being arranged.
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Full Legal Name - This is the full legal name of the individual for whom the funeral service is being arranged.
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First Name
Middle Name
Last Name
Are there any aliases?
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Please provide the legal residence.
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In what County is the legal residence located?
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Is the legal residence inside the city limits?
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YES
NO
Please enter Date of Birth
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Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
2014
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2012
2011
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1927
1926
1925
1924
1923
1922
1921
1920
Year
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Personal Details
What is the County and State of Birth?
County of Birth?
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State of Birth?
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What is the Gender and Race?
Gender?
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Race?
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Marital Status
Current Marital Status
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Married
Widowed
Divorced
Separated
Never Married
Please provide spouse's full legal name.
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First Name
Middle Name
Last Name
Please provide spouse's full name prior to first marriage.
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First Name
Middle Name
Last Name
Last name prior to first marriage
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Father's full name prior to first marriage
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First Name
Middle Name
Last Name
Mother's full name prior to first marriage.
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First Name
Middle Name
Last Name
Other Information
Military Service?
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YES
NO
Which Military Service
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Highest level of education completed
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Occupation and Industry?
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Next of kin (N.O.K.) name, relationship, phone number, and email address
The next of kin will authorize Endswell to proceed with the aquamation, cremation, or green burial service. If married, please provide contact information for spouse. If divorced, separated, or never married, please provide contact information for children, if any. If there are multiple children, please provide their names and contact information. If there are no children, please provide information for siblings or parents.
Next of kin name
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First Name
Last Name
Next of kin email
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example@example.com
Next of kin Relationship
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Next of kin Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
If there are any special spiritual or religious requests or if you or the family would like to arrange a viewing (visitation) of the body, please note them here.
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Other Details
How many death certificates would you like us to order?
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For aquamation and cremation services, to whom should we deliver the urn?
First Name
Last Name
To where should we deliver the urn?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Immediate Need
The following questions are necessary when there is a need for services in the immediate future.
Is there an immediate need for services from Endswell?
If you anticipate the need for our services in the coming days or weeks, please select YES.
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YES
NO
If you are working with hospice, please enter their name and contact number.
Name of hospice contact
First Name
Last Name
Phone number of hospice contact
Please enter a valid phone number.
Format: (000) 000-0000.
If death has occurred, please enter date of death.
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Month
-
Day
Year
Date
If death has occurred, what is the address at that location?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If death has occurred, what County did it occur in?
If there is a doctor or nurse practitioner you are working with, please provide their name and contact number.
Name of doctor or nurse practitioner
First Name
Last Name
Phone Number of doctor or nurse practitioner
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide the Social Security Number.
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