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Use this form to provide us with as much information as you can regarding the person who the pre-arrangement is for. All of the questions asked are used for legal forms such as the death certificate. (Any questions not answered will be left blank on the final death certificate.)

Pre-Arrangement Client Information

Personal Information

Full Name of person who the pre-arrangements are for. (First, Middle Initial, Last)

Street

City

State/Province

ZIP/Postcode

Date of Birth

Social Security Number

Place of Birth (City/Town, State)

Marital Status

Father's Name (If Known)

Spouse's Name

Mother's Name (If Known)

Spouse's Maiden Name

Mother's Maiden Name

Self Described Race

WhiteAfrican AmericanOther

Of Hispanic Origin?

NoHispanicPuerto RicanMexicanOtherUnknown

Work/Education History

Education Level

Grade-School

High-School

Some College

Associate's Degree

Bachelor's Degree

Masters-Degree

Doctorate

Occupation (Job title for most of working career) Do Not use Retired

Company Name (Company worked for longest)

Business Field (Manufacturing, Service, etc.)

MILITARY RECORD

Military Service?

YesNo

Family Member in Charge of this Cremation

Name of Person Legally in charge of Cremation Arrangements

Your relationship to person these pre-arrangements are for

Street address of “Person in Charge”

City / State / Zip

Person in Charge Telephone and Email Address

Number of Certified Copies of the Death Certificate you need? ($ 20. per copy)

Please ask any questions you may have.

Payment Options for Pre-paying a Cremation Service.

Cash

Check

Credit Card or Debit Card: A 3.75% fee will be added to the total for all pre-arrangements paid via credit/debt card. This fee is imposed upon us by the credit card company.

* Click on the “Monthly Payment Program" tab on the home page for monthly payment options.

By submission of your information to us you are requesting that a Funeral Director contact you with the intention of pre-paying for these cremation arrangements. Please click HERE to view the services and costs associated with our Direct Cremation, prior to pre-payment. Please note: We do not hold un-paid pre-arrangement information longer then 30 days unless the patient is currently enrolled in a Hospice Program. We do not accept pre-payment and/or issue policies on Clients currently on Hospice with life expediency of six months or less.

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