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Additional Information
RECIPIENT INFO
Step
1
of
2
50%
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.
Recipient
Name
First
Middle
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Age
Sex
Male
Female
Race
Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Education Level
Veteran
Yes
No
Branch:
Rank:
Serial Number
Military Honors
Yes
No
Marital Status
Married
Widowed
Divorced
Not Married
Name of Spouse (with Maiden Name)
First
Last
Fathers Name
First
Last
Is Father Living
Yes
No
Mothers Name
First
Maiden
Last
Is Mother Living
Yes
No
Optional
Church Affiliation
Cemetery Name
Section #
Lot #
Lot Owner
First
Last
Clubs, Organizations, Special Interests, Hobbies, etc.
Clergy
Phone (Clergy)
Section Break
Retired
Yes
No
Occupation
Place of Employment
Next of Kin
First
Last
Relationship
Phone (Home)
Phone (Cell)
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Obituary Information
Relatives
Name
City, State
Relationship
Children - Oldest to Youngest Followed By Siblings - Oldest to Youngest
Number of Grand Children
Number of Great Grand Children
Number of Great Great Grand Children
Preceded in Death by
Donations to:
In Lieu of flowers
Those who wish
Special Instructions
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.
Name
Relationship
Witness Name
First
Last
Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
How did you find out about us?
I (we) have identified elected to waive the right to identify the human remains at the funeral home.
Declined ID Viewing:
I (we) have identified the human remains that were delivered to the funeral home as the decedent, and have authorized the funeral home to deliver the decedent to the crematory for cremation
ID Viewing
Was the Death caused by an infectious, contagious, or communicable disease?
Yes
No
If yes, please explain
Select one
The decedent's remains DO NOT contain a pacemaker, radioactive implants or any other device that could be harmful to the crematory. They are safe to cremate.
I have instructed the funeral home to remove or arrange for the removal of these devices or to properly dispose of them prior to Cremation. Additional costs may apply. All costs are on GPL
The following list contains all existing devices(including all mechanical, radioactive implants and prosthetic devices) which are implanted in or attached to the decedent that should be removed prior to cremation.
I hereby authorize Crematory to properly dispose of or recycle any surgical steel remaining after cremation
All personal property and effects delivered with the remains of the decedent to the crematory, including jewelry, clothes, hair pieces, dental bridgework, eyeglasses, and shoes, will be destroyed in the cremation process or otherwise discarded by the Crematory, in its sole discretion, unless specific instructions for delivery are given below. If no specfic instructions are given, I/we release the Funeral Home and Crematory from liability for these items.
Items to be delivered to Authorizing Agent or Designee:
After the cremation has taken place, the cremated remains have been processed and the processed cremated remains placed in the designated receptacle, Crematory will arrange for the disposition of the cremated remains as follows, and the Authorizing Agent(s) hereby authorizes Crematory to release, deliver transport or ship the cremated remains as specified, Choose one of the following
Deliver the cremated remains to:
Place cremated remains in:
Deliver the cremated remains to the U.S. Postal Service for shipment by Registered, Return receipt mail to:
Deliver the cremated remains to________________by(date & time)____________
To
Date
Time
Place cremated remains in:
Temporary Plastic Container
Urn
Divide into___________ keepsake portions and place in:
Urn (type:_____________________________)
Divide into ________________ keepsake portions
Place keepsake portions in:
Keepsake Urns
Return in plastic bag or containers
Keepsake urns (type________________)
Mail to:
Other specific instructions
Relation of Authorizing Agent
Served in the capacity of_______________ to the decedent
State of Authorization
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