Decedent Intake Form

1

Decedent's Legal Name* This field is required.Full Name

First, Mid, Last Name

2

Decedent’s Aliases or AKAIf the decedent was known by any other name. (Leave blank if Unknown)

3

Decedent’s Date of Death* This field is required.

Date

4

Decedent’s Place of Death / Case Number* This field is required.If your loved one is located at medical examiner's office or coroners office please include case number

5

Decedent’s Address* This field is required.

Street Address ( Number & Street )

Apartment or Suite Number

City or Town

State / Province

Zip Code

Country

6

Decedent’s Date of Birth* This field is required.

Date

7

Decedent’s Place of Birth* This field is required.

8

Decedent’s Approximate Weight* This field is required.

9

Does the Decedent have a Social Security Number* This field is required.

YES

NO / UNKNOWN

10

Decedent’s Social Security Number* This field is required.

11

Decedent’s Occupation & Industry* This field is required.(RETIRED NOT ACCEPTABLE)

12

Decedent’s Race* This field is required.

13

Decedent’s Father's Name* This field is required.If unknown Please type Unknown below

14

Decedent’s Mother's Full Maiden Name* This field is required.If unknown Please type Unknown below

16

Decedent’s Surviving Spouse's Full Maiden Name* This field is required.If unknown Please type Unknown below

17

Decedent’s Education* This field is required.Please select the highest level of education (if unknown select 8th grade or less)

8th Grade or Less

9th - 12th Grade, No Diploma

High School Graduate or GED

Some College Credits

Associate's Degree

Bachelor's Degree

Master's Degree

Doctorate, Professional Degree or Phd

18

Did the Decedent ever served in the US Armed Forces?* This field is required.Any US military service

YES

NO

19

Legal Name* This field is required.Full Name of Informant / Next of Kin

First, Mid, Last Name

20

Relationship to Decedent* This field is required.Informant / Next of Kin's Relation to the Decedent

21

Email* This field is required.Informant / Next of Kin's Email

example@example.com

22

Phone Number* This field is required.Informant / Next of Kin's Phone Number

Area Code

Phone Number

23

2nd Phone NumberLeave blank if there's no other number

Area Code

Phone Number

24

Address* This field is required.Informant / Next of Kin's Address

Street Address (Number & Street)

Apartment or Suite Number

City or Town

State / Province

Postal / Zip Code

Country

25

Name of Masjid* This field is required.If not sure type unknown

26

Address of Masjid* This field is required.If not sure type Unknown

27

Time of Prayer* This field is required.If not sure type Unknown

Date and Time

28

Vehicle* This field is required.Do you require a Vehicle to transport the casket?

YES

NO

29

Please select the Type of Vehicle on the next pageA standard funeral hearse has a lower clearance and less interior cargo space compared to a funeral minivan. The sleek appearance of standard hearse may be more attractive when leading processions or performing other duties associated with a funeral service. Minivans have more space to accommodate storage or transportation of individuals.

30

Select Type Vehicle* This field is required.A standard funeral hearse has a lower clearance and less interior cargo space compared to a funeral minivan. The sleek appearance of standard hearse may be more attractive when leading processions or performing other duties associated with a funeral service. Minivans have more space to accommodate storage or transportation of individuals.

Minivan Hearse: $495.00 (Within 30 miles range. Additional mileage is $5.00 per mile)

Standard Hearse: $595.00 (Within 30 miles range. Additional mileage is $5.00 per mile)

31

Viewing* This field is required.Do you require a a viewing?

YES

NO

32

Please select the viewing room* This field is required.

Room A: Includes supervision (40-70 People) 1 Hour $500.00

Room A: Includes supervision (40-70 People) 2 Hours $800.00

Room B: Includes supervision (25-35 People) Per hour $300.00

33

Wash* This field is required.Will your family participate in the religious wash?

YES

NO

34

Please select the Type of Casket on the next pagePine Wood Box Caskets - Plain, Simple, Sturdy, Affordable handmade high-quality build. Caskets come in many beautiful finish to complete a high-quality, wood-build product to create a luxurious effect and allows for easy transport.

35

Please select the Type of Casket* This field is required.Pine Wood Box Caskets - Plain, Simple, Sturdy, Affordable handmade high-quality build. Caskets come in many beautiful finish to complete a high-quality, wood-build product to create a luxurious effect and allows for easy transport.

Pine Wood Casket

Casket (Options available upon request)

36

Method of Disposition* This field is required.

Local Burial

International Burial (Shipping)

37

Name of Cemetery* This field is required.

38

Location of Cemetery* This field is required.Address or location

39

Date of Burial* This field is required.

Date

40

Final Destination & Airport Name* This field is required.Country and Airport arrival

41

Name & Relationship of Person(s) Receiving Remains at Final Destination* This field is required.

42

Address of Person(s) Receiving Remains at Final Destination* This field is required.

43

Phone Number of Person(s) Receiving Remains at Final Destination* This field is required.

44

Number of Certified Death Certificates Needed* This field is required.* The City of New York Department of Health charges $20.00 for EACH Certified Death Certificate Copy. * Pickup or Certified Mail EXTRA FEE.

Type in number of copies

45

Your Email* This field is required.Please supply an email so we can send you a copy of this form for your records

example@example.com