Reflection Park Interest & Needs Form

This brief intake helps us learn a bit more about you and your wishes so we can be thoughtful and efficient in how we follow up. By providing this information, you’re helping us make the next steps as seamless and supportive as possible.
Please enter your name and contact information.
Name*

First NameLast Name
Preferred Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you considering burial arrangements at Reflection Park?*
Please let us know what questions you have regarding natural burial*
Which situation most accurately describes your needs? *
We’re here to help make things as simple and peaceful as possible. If you would prefer to speak with someone directly, please call us at 443-840-6775
Who is the person intended to be buried (the Beneficiary)?
Beneficiary's Name*

First NameLast Name
Beneficiary's Date of Birth

MonthDayYear
Date
Your relationship to Beneficiary *
How many cremated remains do you wish to bury?*
Decedent's Name*

First NameLast Name
Decedent's Date of Birth*

MonthDayYear
Date
Date of Death*

MonthDayYear
Date
Your relationship to Decedent*
Which area of Reflection Park feels most fitting for your needs?
How many burial spaces do you wish to secure?
Will you be the Purchaser of the burial space(s)?
Please provide the contact information for the Purchaser
Purchaser Name

First NameLast Name
Purchaser's Date of Birth

MonthDayYear
Date
Purchaser Email
example@example.com
Purchaser Phone Number
Please enter a valid phone number.
Purchaser Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will you be the Owner of the burial space(s)?
Please provide contact information of the Owner
Owner Name

First NameLast Name
Owner Email
example@example.com
Owner Phone Number
Please enter a valid phone number.
Owner's Date of Birth

MonthDayYear
Date
Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will there be a Co-Owner of the burial space(s)?
Co-Owner Name*

First NameLast Name
Co-Owner Email*
example@example.com
Co-Owner Phone Number*
Please enter a valid phone number.
Co-Owner's Date of Birth

MonthDayYear
Date
Is Co-Owner's address the same as yours?

YesNo
Co-Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your relationship to Co-Owner?*
Are you the person with legal authority to make decisions for burial (aka Authorized Agent)?*

YesNoUnsure
Please provide any additional considerations we should be aware of, for example, military or first responder honors, religious or cultural traditions, or anything else you wish to tell us.
Authorized Agent's Name*

First NameLast Name
Authorized Agent's Phone Number*
Please enter a valid phone number.
Authorized Agent's Email*
example@example.com
Authorized Agent's Date of Birth

MonthDayYear
Date
Authorized Agent's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Agent's relationship to decedent
Have you already connected with a funeral home?
Please provide name of Funeral Home*
Please provide name of Funeral Director
Funeral Director's Email
example@example.com
Funeral Director's Phone Number
Please enter a valid phone number.
Second Decedent's Name*

First NameLast Name
Second Decedent's Date of Birth*

MonthDayYear
Date
Second Decedent's Date of Death*

MonthDayYear
Date
Your relationship to Second Decedent*
Are you the person with legal authority to make decisions for burial for second decedent (aka authorized agent)?*

YesNoUnsure
Please provide any additional considerations for Second Decedent we should be aware of, for example, military or first responder honors, religious or cultural traditions, or anything else you wish to tell us.
Third Decedent's Name*

First NameLast Name
Third Decedent's Date of Birth*

MonthDayYear
Date
Third Decedent's Date of Death*

MonthDayYear
Date
Your relationship to Third Decedent*
Are you the person with legal authority to make decisions for third decedent's burial (aka authorized agent)?*

YesNoUnsure
Please provide any additional considerations for Third Decedent that we should be aware of; for example, military or first responder honors, religious or cultural traditions, or anything else you wish to tell us.
What is your preferred next step? *
Should be Empty:

This brief intake helps us learn a bit more about you and your wishes so we can be thoughtful and efficient in how we follow up. By providing this information, you’re helping us make the next steps as seamless and supportive as possible.