Vital Records Intake Form

Vital Records Intake Form

This optional form may be completed before or after a passing. It helps Clearview Cremation gather the information needed to prepare official vital records, including the death certificate, and to coordinate care once your loved one comes into our care. Our team will review everything with you before anything is filed. Submitting this form does not replace calling us when a passing occurs. If your loved one has passed or passes after this form is submitted, please call Clearview Cremation at 855-704-3344 so our team can assist right away. This form usually takes about 10 minutes to complete.
Has your loved one already passed?
Loved One Information
Full Legal Name

First NameMiddle NameLast NameSuffix
Also Known As (If Applicable)
Only complete this section if your loved one had a different legal, married, or commonly used name.
Sex Assigned at Birth
Date of Birth

MonthDayYear
Date of Death (or Date Found)

MonthDayYear
Enter the date the individual passed away. If the exact date is unknown, enter the date they were found.
Age at Time of Passing
Days in Year
Was this the actual date of death or the date the individual was found?
Social Security Number (SSN)
Enter 999-99-9999 if decedent was never issued a SSN or if SSN is unknown.
State of Birth (or province/country if born outside U.S.)
City of Birth
County of Death
Does your loved one have a pacemaker or any implanted medical device?
Place of Death

Other
Place of Death Facility Name (if applicable)
Address of Place of Death

Street Address

Street Address Line 2

CityState

Zip Code
Loved One's Home Address

Street Address

Street Address Line 2

CityState

Zip Code
County of Loved One's Home Address
Marital Status & Spouse Information
Loved One's Marital Status
Married Simultaneous Death refers to a situation where both spouses pass away at the same time or under circumstances where the order of death is uncertain.
Loved One's Spouse's Name

First NameMiddle NameLast Name
Loved One's Spouse's MAIDEN Name (Last Name Prior to Marriage)
Loved One History
Occupation (Please do not enter "Retired")
Enter the primary occupation the individual held during their working years. Please do not enter “Retired”.
Business or Industry
Associated with Occupation.
Race (Select all that apply)

Other (Do NOT select for Hispanic/Latino — answer below)
Hispanic/Latino Origin
Select Specific Hispanic/Latino Origin
To what American Indian tribe did your loved one belong?
Highest Level of Education
Veteran Status (US Armed Services)
If Yes, did a service-connected disability contribute to the veteran's death?
Parent Information
Loved One's Father's Legal Name

First NameMiddle NameLast NameSuffix
Loved One's Mother's Legal Name

First NameMiddle NameLast NameSuffix
Loved One's Mother's Maiden Name (Last Name Prior to Marriage)
Informant Information

The informant is the person providing information about the decedent in this form. Please enter your own details below–not the decedent’s.
Informant's Full Legal Name

First NameMiddle NameLast NameSuffix
Informant's Relationship to Loved One
Informant's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Informant's Address

Street Address

Street Address Line 2

CityState

Zip Code
Death Certificates

Each Clearview Cremation package includes one certified death certificate at no additional cost. If you already know how many extra copies you’ll need, please enter the number below. If you're unsure, feel free to leave these fields blank — we can always help you decide later.
Desired type of INCLUDED death certificate?
OPTIONAL: Additional Short-Form Death Certificates ($15 each)
These do not include cause of death or Social Security number and are typically used for personal records or non-financial matters.
OPTIONAL: Additional Long-Form Death Certificates ($15 each)
These include the cause of death and Social Security number, which are often needed for banks, insurance, pensions, and other official matters.
OPTIONAL: Expedited Processing & FedEx Overnight of Death Certificates ($80)
Select “YES” above if you would like to request expedited processing and overnight delivery of the certified death certificate. This fee includes priority handling with the Department of Health and FedEx tracked overnight shipping directly to your address. Please note that processing time depends on when the certifying physician completes the cause of death and when the medical examiner grants authorization. While Clearview Cremation will make every effort to expedite this process, timing ultimately depends on these third parties and may be outside of our control.
Optional Remembrances

These are completely optional and can also be discussed later.
OPTIONAL: After your loved one comes into our care, would you like us to collect fingerprints?
OPTIONAL: After your loved one comes into our care, would you like us to request locks of hair?
OPTIONAL: Would you like to receive fingerprints of your loved one?
OPTIONAL: Would you like to request locks of hair? ($50 each)
Is there anything else you would like our team to know?
This is completely optional. You may use this space to share any family circumstances, timing concerns, special requests, religious or cultural considerations, or anything else that may help us support you and your loved one with care.
Should be Empty:

Vital Records Intake Form

Loved One Information

Marital Status & Spouse Information

Loved One History

Parent Information

Informant Information

Death Certificates

Optional Remembrances