A Sacred Moment

Cremation Arrangement Form

DECEDENT INFORMATION
Decedent's Name
What prompted you to fill out this form today?
If applicable.
Date of Death
Sex
Was Decedent in the US Armed Forces?
Date of Birth
City, County
Or foreign country
Decedent's Education
Was Decedent of Hispanic Origin?
Decedent's Race
If American Indian or Alaska Native was selected above.
if applicable
Decedent's Residence Street Address
Inside City Limits?
Years
Marital Status
Surviving Spouse's Name
prior to 1st marriage
Do not list Retired
Father's Name
Mother's Name
use Maiden Name for Last Name
INFORMANT'S INFORMATION
Person making arrangements.
Informant's Name
Address
Home Phone
Cell Phone
NEXT OF KIN INFORMATION
Please list the names of living legal next-of-kin to the deceased below.
Spouse
Registered Partner
Physician Name
Physician Phone
Physician Address
Cemetery Address
Cemetery Phone
SELECT SERVICES
Direct Cremation Only
Viewing Prior to Cremation
Witnessed Placement prior to Cremation
Expedited Cremation (within 5 days)
Shipment of Cremated Remains
Scattering of Cremated Remains
If requested
$20 per copy
Method of payment at time of arrangements
PLEASE PRINT THIS PAGE BEFORE SUBMITTING