Registration

Informant's Information (Person in Charge of Arrangements) - Step 1 of 6

Informant's Information
(Person in charge of arrangements)

First Name *

Please enter informant's first name

Last Name *

Please enter informant's last name

Phone Number *

Please enter the best contact phone number for you

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Confirm Email

This Registration is for: *

Funeral/Death
Pre-Planning

Relationship to recipient of services *

Your relationship to person for whom services are planned

Information for Whom the Service is Planned

PERSONAL & FAMILY INFO

First Name *

Please enter first name

Middle Name

Please enter middle name

Last Name *

Please enter last name

Maiden Name

Please enter maiden name, if applicable

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Please enter date of birth

Place of Birth

Date of Death, if deceased

Date

Time

Please enter date of death for the deceased

Social Security Number

Martial Status

Married
Never Married
Divorced
Widowed / Widower

Spouse's Name

Please enter spouse's full name, if applicable

Spouse's Maiden Name

Please enter spouse's maiden name, if applicable

Date of Marriage

Please enter date of marriage, if applicable

Father's Name *

Please enter father's name; if unknown, enter "Unknown".

Father's Place of Birth *

Please enter father's place of birth; if unknown, enter "Unknown"

Mother's Name *

Please enter mother's name and (maiden name); if unknown, enter "Unknown"

Mother's Place of Birth *

Please enter mother's place of birth; if unknown, enter "Unknown"

Additional Family Members

Please list additional family members and relationship

Photo

Click or drag a file to this area to upload.

Please attach photo if available (3 MB maximum size)

WORK & EDUCATION HISTORY

Highest Education Level Attained *

Grade School
High School
Bachelor's Degree
Master's Degree
Doctorate
Other

Schools / Educational Institutions

Please list schools, colleges, universities and other educational institutions attended and degrees, if applicable.

Employment

Please list companies where employed, if applicable

Business Field

Please enter business category

MILITARY RECORD

Served in Military

Military Branch

Air Force
Air Force Reserve
Air National Guard
Army
Army Reserve
Army National Guard
Coast Guard
Coast Guard Reserve
Marine Corps
Marine Corps Reserve
Navy
Navy Reserve

Dates of Service

Please enter date range for active service

Rank at Discharge

Please enter rank at time of discharge

Date of Discharge

Please enter date of discharge

Do You Have a Copy of Discharge Papers?

Service During War Time

War/Theatre Served In

Please list wars/conflicts and theatre of operations served in

Funeral Service Request

Place of Service Requested *

Funeral Home
Church / House of Worship
Cemetery
Other

Visitation *

One Night
Morning of Funeral

Religious Denomination (or Affilitation) *

Please enter religious affiliation; if none, please enter "None"

Lodge / Union / Association Membership

Please list membership in any lodges, unions or associations.

Disposition Request

Disposition Type *

Traditional Burial
Green Burial
Mausoleum
Cremation
Donation to Science / Medicine
Other

Cemetery Name & Location

Please enter cemetery name and location, if applicable

Lot Number and Grave Number

Please enter cemetery lot number and grave number, if applicable

Summary Details

Additional Instructions

Please enter any additonal instructions or requests you may have

Memorial Requests or Donations

Please enter any memorial request or donation requests you may have on behalf of the deceased

Contact Options

Contact Instructions (Please check one) *

Please send me information about pre-arrangements
Please contact me to set up appointment
No appointment needed; just keep my request and info on file

Please confirm you are a human and not a robot. *

What is the first letter of the alphabet?

Please verify you are not a robot *

What is the second letter of the alphabet?

Please answer the question to prove you are human.

Contact Info

Contact Info

Informant's Information
(Person in charge of arrangements)