Funeral Assistance Application
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Baby Name
*
Baby Birth Date
*
-
Month
-
Day
Year
Date
Date of Loss
*
-
Month
-
Day
Year
Date
Hospital where loss occurred
*
Have you received funeral assistance of any kind?
*
What kind of assistance are you applying for?
*
Please Select
Burial Plot
Urn
Casket
Headstone
Funeral Services
Please list the name, address and number of the business you need help with payment. For example, funeral home name, headstone company name, etc.
*
Do you understand that no money will be paid directly to applicant? All money will be paid directly to place of business. We do not provide reimbursements.
*
Please tell us a little about your story. In order to continue our funeral assistance program, we will post and ask the public for donations each time an individual applies. We will require you to allow us to share minimal details. We will never include names or any identifying information. Please only include information you would like us to share. It can be as vague as (I lost my baby girl at 18 weeks) or as in-depth as you would like.
*
Please note this is for Kentucky residents only at this time. Are you a Kentucky resident?
*
This program is only for residents who had a loss in the last 6 months. Please verify your loss was in the last 6 months.
*
Please upload a copy of an invoice or quote from the business you are trying to purchase an item from. Please note - we do not provide any kind of reimbursement. We only provide payment to a place of business.
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