Name: _____________________________________________________________________________

Alias’s, AKA’s or Maiden Name: _______________________________________________________

Address___________________________________________________________________________

Phone Number: ______________________________ Alternate or Fax:________________________

E-mail address: _____________________________________________________________________

Date of Birth: _____________ Place of Birth (State or Country):______________________________

Social Security Number:____________________ Are you: Male or Female

Marital Status (circle one): Married   Divorced   Widowed   Never Married

Served in U.S. Military? Yes No      If Yes, do you have Discharge Papers (DD 214)? Yes No

Height: _________ Weight: _________ Age: ________ Religion: ____________________________

Ethnic Background: ____________________________________

Father’s Name___________________________________________ Father’s place of birth___________

Mothers Name (Maiden) ____________________________________ Mother’s place of birth__________

Physician’s Name_____________________________________________________________________

Physician’s Address: ___________________________________________________________________

Physician’s Phone #____________________________ Physician’s Fax #_________________________

Next of Kin or Authorized Agent’s Name: ___________________________________________________

Relation to Decedent: _______________________________ Power of Attorney? Yes No

Address:_____________________________________________________________________________

Phone #____________________ Fax #____________________ e-mail__________________________

Services:
What is to happen upon death?

The remains are to be: Cremated   Buried   Intact   (circle One)

Are the remains to be embalmed? Yes No

Generally embalming is not required. Embalming may be selected if the remains are going to be viewed prior to cremation or burial, or if they are being transported internationally. Check with your funeral director for the governing law and rules.

Will there be organ or tissue donation? Yes No

Will there be any kind of funeral or memorial service? Yes No

Where will the service take place? ________________________________________________________

What kind of service? Funeral Memorial Service   Vigil (rosary)   Graveside   Viewing

Will the remains be viewed prior to burial or cremation? Yes No

If yes, do you want the remains to be dressed? Yes No If yes, clothes must be brought to funeral home

If the service takes place after a cremation will the ashes be present? Yes No

Will there be a graveside or niche side service? Yes No

Will there be a reception? Yes No If yes, where? ______________________________________

Will a military honor guard be requested? Yes No Will a flag be folded, draped or presented? Yes No

What is the final place of disposition? Circle one.

Cemetery   Residence   Scatter at Sea   Other____________________________________

If a cemetery or residence:
Name: _______________________________________________________________________

Address: ______________________________________________________________________

Is there a preference for the type of casket or urn? ___________________________________________

How many certified copies of the death certificate will be requested: _______________?

Are there copies of the Will, Trusts, Powers of Attorney, Health Care Directives of decedent available?

If yes, which documents________________________________________________________

Other specific requests or questions for the funeral director:
__________________________________________________________________________________

P.O. Box 1252
Eagle Point, Oregon 97524
Tel: 1-888-441-2655
Website: www.forcremation.com Email: info@forcremation.com