At-Need Arrangements Form

Personal Information of Deceased

First Name

Middle Name

Last Name

Decedent Information

Decedent's last known address

Date of Birth

Social Security Number

Date of Death

Time of Death

Place of death

Name of Facility

If at medical examiner, do you have the case number?

Was this a Covid-19 related death?

YesNo

Birth Sex

Does the decedent have a pacemaker?

What is the approximate weight of the deceased?

Was the decedent an organ donor?

Decedent Biographic Information

Decedent's marital status at time of death

Decedent's race/ethnicity

Decedent's place of birth

Decedent's occupation and industry

Decedent's highest level of education

Decedent's father's name

Decedent's mother name(use maiden name as last name)

Military

Is the decedent a veteran?

YesNo

Do you have the DD214 document?

YesNo

Branch of Service

Honorably Discharged

YesNo

Insurance

Is there an insurance policy?

YesNo

Insurance Company

Insurance Policy #

Beneficiary Info

Funeral Arrangement

Funeral Arrangement Options

Do you wish to have services held in funeral home or church?

How many death certificates will you need?

Do You Have a Prearrangement on File with Us?

YesNo

If Yes, Under What Name?

Cemetery Information

Do you have a deed to a plot?

YesNo

If yes

What is the name of the cemetery?

What is the section, grave, lot information?

Do you wish to purchase a cemetery plot?

YesNo

Do you have a preference of a cemetery?

Informant

Name

Relationship to Decedent

Address

Email Address

Telephone

Anti-Spam Security Question

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