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

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

How did you find out about us?

Additional Information

RECIPIENT INFO

Step 1 of 2

Recipient

Optional

Section Break

Obituary Information

Preceded in Death by