Additional Information - Simple Alternatives Funeral Home, Inc.

In order to better serve you and be in a position to work ahead we need this basic information. Although this information is sensitive in nature it is necessary to be able to complete the death certificate along with necessary authorizations and provide a starting point for an obituary. If you have already pre-planned we have this information on file.

Deceased

Deceased *

Middle Name *

Last Name *

Place of Death *

Date of Death *

Time of Death *

Street Address *

Address Line 2

City *

State/Province *

ZIP / Postal Code *

Country *

County of Death *

City of Death *

Twp./Boro of Death *

State of Death *

Age *

Sex *MaleFemale

Race *

Date of Birth *

Educational Level *

Retired *YesNo

Occupation *

Place of Employment *

Veteran *YesNo

Marital Status *MarriedWidowedDivorcedNot Married

Fathers First Name *

Fathers Last Name *

Is Father Living *YesNo

Mothers *

Maiden Name *

Last Name *

Is Mother Living *YesNo

Church Affiliation *

Cemetery Name *

Section # *

Lot # *

Lot Owners *

Last Name *

Clubs, Organizations, Special Interests, Hobbies, etc.

Clergy *

Phone (Clergy) *

Contact / Death Certificate / Obituary Information

Phone of Next of Kin *

Email of Next of Kin *

Person Providing Information *

Last Name *

Relationship *

Phone (Home) *

Phone (Cell) *

Email *

Street Address *

Address Line 2

City *

State/Province *

ZIP / Postal Code *

Country *

Obituary Information

Relatives (Children First - Oldest to Youngest, Siblings Second - Oldest to Youngest)

Name *

City, State *

Relationship *

Number of Grand Children *

Number of Great Grand Children *

Number of Great Great Grand Children *

Preceded in Death by

Donations to: *In Lieu of flowersThose who wish

Special Instructions

Will you be using Insurance to Pay? *YesNo

I (we) hereby represent that I am (we are) of the same and nearest degree of relationship to the deceased and/or are legally authorized or charged with the responsibility for such burial and/or other disposition. *Agree

Name *

Relationship *

Date *

How did you find out about us?

Leave this field empty

Deceased

Contact / Death Certificate / Obituary Information

Obituary Information

Preceded in Death by

Contact Information