RECIPIENT INFOStep 1 of 250%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.RecipientName First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AgeSex Male FemaleRaceDate of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Education LevelVeteran Yes NoBranch:Rank:Serial NumberMilitary Honors Yes NoMarital Status Married Widowed Divorced Not MarriedName of Spouse (with Maiden Name) First Last Fathers Name First Last Is Father Living Yes NoMothers Name First Maiden Last Is Mother Living Yes NoOptionalChurch AffiliationCemetery NameSection #Lot #Lot Owner First Last Clubs, Organizations, Special Interests, Hobbies, etc. ClergyPhone (Clergy)Section BreakRetired Yes NoOccupationPlace of EmploymentNext of Kin First Last RelationshipPhone (Home)Phone (Cell)Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Obituary InformationRelativesNameCity, StateRelationship Children - Oldest to Youngest Followed By Siblings - Oldest to YoungestNumber of Grand ChildrenNumber of Great Grand ChildrenNumber of Great Great Grand ChildrenPreceded in Death byDonations to: In Lieu of flowers Those who wishSpecial InstructionsI (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. NameRelationship Witness Name First Last DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How 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 ViewingWas the Death caused by an infectious, contagious, or communicable disease? Yes NoIf yes, please explainSelect 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 GPLThe 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)____________ToDateTimePlace cremated remains in: Temporary Plastic Container Urn Divide into___________ keepsake portions and place in:Urn (type:_____________________________)Divide into ________________ keepsake portionsPlace keepsake portions in: Keepsake Urns Return in plastic bag or containersKeepsake urns (type________________)Mail to:Other specific instructionsRelation of Authorizing AgentServed in the capacity of_______________ to the decedentState of Authorization