Decedent Information Worksheet
In order to assist in the arrangement process, please complete this on-line form and submit it to us by clicking the SUBMIT button. We will contact you when we receive it. Thank you.
Media name *
Name that will be used for obituary, name they are known as by others. We encourage the use of maiden name for women.
Your answer
Full legal name *
Your answer
Street address *
Your answer
Street city *
Your answer
Street state *
Your answer
Street ZIP *
Your answer
Street County *
Your answer
Is the street address in the city limits? *
Mailing address *
Your answer
Mailing city *
Your answer
Mailing state *
Your answer
Mailing zip *
Your answer
Social security
Your answer
Highest grade completed *
Birth date *
MM
/
DD
/
YYYY
Age *
Your answer
Birth county *
Your answer
Birth state *
Your answer
Father's name *
Your answer
Father living or deceased *
Mother's name *
Your answer
Mother living or deceased *
Mother's maiden name *
Your answer
Decedent's occupation *
Your answer
Type of industry
Your answer
Did the decedent ever serve in the armed forces? *
If yes, please bring a copy of the DD-214 discharge document.
If yes, branch of service?
Your answer
Family info *
Spouse name *
Your answer
Spouse maiden name *
Your answer
Spouse living or deceased *
Surviving family *
ex. Son: John S. Doe, Jr. (wife, Jane). etc.
Your answer
Preceded in death by *
ex. Parents, Husband, Spouse, etc
Your answer
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