SERVICES | AT-NEED FORM

Thanks for taking the time to fill out the At Need Planning Form. By completing the following information at your own convenience, you should find it easier to provide correct information and have some time to think about the type of services you desire.

The information provided on this form will help the funeral home complete the death certificate and other required documents. In addition, this information will assist the funeral director to better understand your initial wishes. Relaying required statistical information can be time consuming. Our desire is to help expedite the final arrangement conference at the funeral home and make the process a little more comfortable.

Please complete (as much as possible) the information on the form and select Submit Information at the end to email to the funeral home. You may also print out the form and bring it with you to the arrangement conference or fax.

If you have any questions, please contact the funeral home at any time. Thanks again for helping us serve you more efficiently.

Last Name:
First Name:
Middle Name:
Sex:	Choose M F
Race:
Date of Birth:	/ /
Place of Birth:	City State OR Country
Date of Death:	/ /
City of Death:
State of Death:
County of Death:
Location of Death:	Home In Transport Emergency Room Hospital Nursing Home Other Place If other, please indicate address:
Name of the Place of Death:
Social Security #:
Education	Primary 0 1 2 3 4 5 6 7 8 9 10 11 12 College 0 1 2 3 4 5+
Usual Occupation: (most of life)
Kind of Business:
Company: (optional)
Marital Status:	Choose Married Never Married Widowed Divorced
Surviving Spouse:
If wife, provide maiden name:
Residence: (street Address)
City/Town:
Inside City Limits:	Choose Yes No
County:
State:
Zip Code:
Length of Residence in County:
Fathers Full Name:
Mothers Full Maiden Name:

Disposition will be:

Choose Earth Burial Mausoleum Entombment Cremation Ship Out of Area Not Sure

If Cremation, disposition of ashes?:

Choose Cemetery Burial or Niche Wall Scatter Take Home Other Not Sure

Name of Cemetery (if applicable):

City: State:

Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming. Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.

The family preference regarding viewing/embalming is:

Choose Public Viewing One time ID view for immediate family only Required by choice of disposition No viewing, no embalming Not sure

I authorize this funeral home to embalm:

Choose Yes No Will Advise

Name of authorizing person:

Relationship to deceased:

Was Decendent ever in the US Armed Forces?:
YES NO (if no, continue to next section)
Branch of Service:
Date Enlisted:	/ /
Date Discharged:	/ /
Honorable Discharge:	YES NO
Military Serial #:
Is copy of discharge papers available?
YES NO (if yes, please bring for us to copy.)

Name of person in charge:
Relationship to deceased
Address:
City
State	Zip
Phone #:
Email:

Preferred Place of Service:	Choose Funeral Home Church Other Location Will Advise
Religious Denomination (optional):
Is there Pre-Need Funeral Insurance on decedent?:	YES NO
If yes, specify type: (i.e. Forethought, Purple Cross, trust, etc.)

Note: Use box below to indicate any additional information that may be helpful at this time. Other details regarding services, merchandise, flowers, financing, etc., will be discussed and finalized at the arrangement conference. PLEASE CALL FOR AN APPOINTMENT. Thank you for completing our online arrangement form.