Cremation Arrangement Form

Decedent's Name *

First Name

Last Name

What prompted you to fill out this form today? *

Pre-planning

Death is imminent.

Death has occurred.

Date of Death

MM

DD

YYYY

Sex

Male

Female

Was Decedent in the US Armed Forces?

Yes

No

Unknown

Date of Birth

MM

DD

YYYY

Decedent's Education

8th grade or less

9th-12th grade; no diploma

High school graduate or GED completed

Some college credit but no degree

Associate Degree

Bachelor's Degree

Master's Degree

Doctorate

Was Decedent of Hispanic Origin?

No, not Spanish/Hispanic/Latino

Yes, Mexican, Mexican American, Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, other Spanish/Hispanic/Latino

Decedent's Race

White

Black or African American

American Indian or Alaska Native*

Asian

Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Other

Decedent's Residence Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Inside City Limits?

Yes

No

Unknown

Marital Status

Married

Married, but separated

Widowed

Divorced

Never Married

Unknown

Domestic Partnership

Surviving Spouse's Name

prior to 1st marriage

First Name

Last Name

Father's Name

First Name

Last Name

Mother's Name

use Maiden Name for Last Name

First Name

Last Name

Informant's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone

(###)

###

####

Spouse

First Name

Last Name

Registered Partner

First Name

Last Name

Physician Name

First Name

Last Name

Physician Phone

(###)

###

####

Physician Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cemetery Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cemetery Phone

(###)

###

####

Direct Cremation Only

Yes

No

Viewing Prior to Cremation

Yes

No

Witnessed Placement prior to Cremation

Yes

No

Expedited Cremation (within 5 days)

Yes

No

Shipment of Cremated Remains

Yes

No

Scattering of Cremated Remains

Yes

No

Method of payment at time of arrangements

VISA

MasterCard

American Express

Discover

Check

Cash