Statistical Information

Statistical Information Form

Please Select One

If you are pre-planning, do you wish to prepay for services?

Yes

Free Text

Decedent/Funeral Recipient Information:

If any of the requested information is unknown at this time, please submit the form without it and we will collect the missing information at a later time.

Legal Name (First – Middle – Last):

Sex (Please select one):

Social Security Number:

Date of Birth:

Place of Birth (City, State):

Complete Street Address:

U.S. Veteran:

Yes

If yes, Name of War & Dates Served:

Marital Status of the person you are making arrangements for. (Please select one):

If Applicable, Name of Surviving Spouse

Father’s Name:

Mother’s Name

Decedent Race:

White

Black or African American

Other

If Other, Please Specify

Decedent of Hispanic Origin:

Yes

If Yes, Please Specify:

Highest Level of Education Completed (Please select one):

Occupation of the Deceased - Type of work done most of life. (Retired is NOT an option):

Industry:

Last Employer:

Free Text

Informant or Next of Kin Information

Informant’s Name:

Relationship to person the arrangements are for (Please select one):

If Other, Please Specify

Complete Mailing Address:

Email Address:

Phone Number: