At-Need Form

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At-Need Form

General Price List

Authorization Form

Funeral Goods and Services Contract

Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form.

At-Need Form

Personal Information of the deceased.

First Name

Middle NameUse a dash (-) if none.

Maiden NameUse a dash (-) if none.

Last Name

Sex

MaleFemaleUnknown

Street

City

State/Province

ZIP/Postcode

Date of Death

Date of Birth

SSN #

Place of Death (Include Name of Hospital)

Place of Birth

If not born in the US, how long have you resided here?

Father's Name

Mother's Name

Mother's Maiden Name

Marital Status

Spouse's Name (Include Maiden name if applicable.)

Date and Place of Marriage

Additional Family MembersPlease use the area above to enter the names of siblings, children and grandchildren.

Race and Ethnic Origin

Asian/Asian Pacific/Pacific Islander (Specify Country) :

Specify Race and Ethnic Origin

Black/African American

Black/African (Specify Country)

Specify Race and Ethnic Origin

Hispanic/Latino (Specify Country)

Specify Race and Ethnic OriginExamples: Black - Cuban; White - Cuban

Native American/Alaska Native (Specify Tribe)

Specify Tribe and Ethnic Origin

White/Caucasian

Refuse to Give

Unknown

Hispanic in Origin

YesNo

If yes, specify below:

Label

Education/Work History

Specify Highest Level of Education Completed

Grade-SchoolHigh School-No DiplomaHigh School Graduate or GEDSome College-No DiplomaAssociate-DegreeBachelor-DegreeMasters-DegreeDoctorate

Usual Occupation (You can not use Retired.)

Kind of Business/Industry (Company Name)

Military Record

Did you serve in the military?

YesNo

Branch of Service

Date Entered Service

Date Discharged

Serial Number

Rank at Discharge

Discharge on file at

Do you have a copy of your discharge papers?

YesNo

Wars Fought In

NAME of Person in Charge of Final Arrangements and their Relationship to the deceased (The Informant's information needed and will appear on the Death Certificate.)INFORMANT

Specify Relationship of Informant to Decease

WifeHusbandDaughterSonRelativeFriend

Person in Charge of Final Arrangements (Informant's) Address

Person in Charge of Final Arrangements Contact number and email