Immediate Need

If a Death Has Just Occurred

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Personal Information of Deceased

Last Name*

First Name*

Date of Birth*

Date of Death*

Social Security Number*

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Preparation Information

Has a Doctor / Coroner Been Notified?

Yes

If Deceased Passed at Home, Do You Permit Us to Embalm the Body?

Yes

Has the Body Been Released for Removal?

Yes

Do You Permit Us to Cremate the Body?

Yes

If Yes, Who Has Granted Permission?

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Personal Information of Person Legally Responsible for Disposition

Last Name*

First Name*

Email Address*

Relationship to Deceased*

Street*

City*

State/Province*

Zip/Postcode*

Primary Phone Number*

Best Time to Reach Via Phone*

Do You Have a Prearrangement on File with Us?

If Yes, Under What Name?

Stillwater

Perry

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