610-750-5057

2741 N. 5th Street

Reading, PA 19605

(610) 750-5057

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Use this form to provide us with the necessary information regarding the person who the pre-arrangement is for. The term "Client", shall refer to the person who this pre-arrangement is for. All of the questions asked are used for legal documents such as the death certificate. Therefore, complete each question thoroughly, do not abbreviate answers. (Any questions not answered will be left blank on the final death certificate.)

Please Note: We will keep Hospice Patients information on file for six months. Please click HERE to view the services and costs associated with our Direct Cremation, prior to pre-payment.

Information regarding who the Pre-Arrangement is for.

Personal Information

First Name of Client

Middle Initial of Client

Last Name of Client

Is this Client currently, or soon to be, enrolled in a Hospice program?

YesNo

Please Note: We will keep Hospice Patients information on file for six months. Please click HERE to view the services and costs associated with our Direct Cremation, prior to pre-payment.

Street

City

State/Province

ZIP/Postcode

Client's Date of Birth

Client's Social Security NumberWe notify Social Security upon death. This number is asked on all types of legal documents, that is why we require it.

Client's Place of Birth (City/Town, State)

Client's Marital Status

Client's Spouse's Name (If Married)

Client's Spouse's Maiden Name (if female)

Client's Father's First & Last Name (If Known)

Client's Mother's First Name (If Known)

Client's Mother's Maiden Name (If Known)

Client's Self Described Race

WhiteAfrican AmericanOther

Is Client of Hispanic Origin?

NoHispanicPuerto RicanMexicanOtherUnknown

Education / Work History

Client's Education Level

Grade-School

High-School

Some College

Associate's Degree

Bachelor's Degree

Masters-Degree

Doctorate

Client's OCCUPATION: Job Title for majority of working career. (Do Not Use Retired)

MILITARY RECORD

Did Client service in the Military?

YesNo

Person Legally in charge of these Cremation Arrangements Today.

Name the Person Legally in charge of Cremation Arrangements.

Their relationship to person these pre-arrangements are for

Street address of “Person in Charge”

City / State / Zip

Person in Charge Telephone and Email Address

Social Security Number of the Person in Charge

Number of Certified Copies of the Death Certificate you need? ($ 20. per copy)We suggest five (5) to Start. You can always order additional copies later.

Urn/Jewelry Booklet

Click on the graphic on the left to download our Urns & Cremation Jewelry Catalog.

LabelIf you selected an Urn, type the name, page number and code number of the urn here.

NEXT-OF-KIN (Who is legally in charge upon the Clients death)I.E.: Spouse, Child, Parent, Sibling, Grandchild, etc.

Next of Kin Relationship to Client

Next-of-Kin address (Town/City, State, Zip)

Next-of-Kin Phone Number

Use this space for any additional information or 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.

Prior to clicking on the Submit Button below, please go back and double check all of your work. Make sure each entry is complete and all names and dates are true and spelled correctly. Once you click "Submit" a pop-up window will appear, at the top of this page, confirming our receipt of your information. If you did not receive that notice, at the top of this page, go back and double check any questions that are highlighted in Red. The pop-up notice may not appear on all hand-held devices.

After submission of your information to us, call our office to arrange an appointment to pre-pay for these services at (610) 750-5057. Please note: We only hold non-paid pre-arrangement information submitted to us for 30 days, unless the patient is currently enrolled in a Hospice Program. We cannot accept pre-payments from a patient who is currently enrolled under a Hospice program. Payment for Hospice patients would be made at time of need except under special circumstances.

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