PURCHASER AND BENEFICIARY INFO:

Please provide information on who will be the Purchaser that will be paying for the pre-arrangements and who will be the Beneficiary receiving the services. If you are making arrangements for yourself, the Purchaser and the Beneficiary will be the same person.

Who are you making arrangements for?

Myself

Someone Else

If making arrangements for someone else, will you be the Purchaser or will they be?

Will you be the one paying for the arrangements or will the person receiving the benefit pay for their own services?

I will be paying for their services with my own funds

I will be paying for their services with their funds

The Beneficiary will pay for their own services

Were you referred by or have you already spoken with one of our PreNeed Sales Agents or other Staff Members?

Matthew Moore

Mandy Moore

Alan Moore

Jordan Moore

No One

Other (not listed)

Is the Beneficiary currently under Hospice care?

Yes

No, but will be entering hospice care soon

Unknown

Your Name

Your Phone Number

Country Code for the USA is: 1

Country

(###)

###

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Your Phone Type

Please specify what type of phone number this is:

Your Email Address

Your Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Beneficiary Full Name

If arranging for someone else, please provide their full name here. If arranging for yourself please enter "Self" here.

Beneficiary Phone Number

If arranging for someone else, please enter their phone number here. Country Code for the US is: 1

Country

(###)

###

####

Beneficiary Email Address

If arranging for someone else, please enter their email here.

CREMATION SERVICES INFO:

Please select the services and other items that you want included in your contract.

**Please note there will be a $125 Processing Fee added to any Pre-Paid contracts to cover state fees & annual trust accounting & maintenance.

What Type of Services are you interested in?

(Please see our Pricing page for descriptions of our packages and other services)

Simple Cremation - $945

Veteran Simple Cremation - $1145

Expedited Simple Cremation - $1245

Premium Direct Cremation - $1395

Veteran Premium Direct Cremation - $1495

Simple Cremation with Private Family Goodbye - $1495

Other Services, not listed here (provide details below)

Other Services, not listed (please provide additional details):

Interested in Adding a Travel Assurance Plan for $495?

A Travel Assurance Plan will cover the cost of sending you to us if death occurs outside of a 75 mile radius from you legal residence, whether you are in the US or farther abroad in the World. Alternately they will also cover the cost to have you cremated with a partner crematory near the place of death and have the cremated remains mailed/shipped to the family.

Yes

Maybe, I would like additional information on this

Select your preference for the Disposition of Cremated Remains

(Please select how the cremated remains should be handled)

PICK UP from AM Cremation & Funeral Care - $0

DELIVER to Approved Recipient (w/in 50 mile radius) - $125 (Included w/ Veteran/Premium Packages)

MAIL to Approved Recipient (USPS Priority Express, U.S. Address) - $195

MAIL to Approved Recipient (USPS Priority Express, Florida Address) - $100

SCATTER AT SEA by Funeral Facility (unattended) - $185

Other Disposition (specify below)

Other Disposition

(If none of the above options apply, please state your preference for disposition here.)

Delivery or Mailing Address & Instructions

(If Delivery or Mailing was selected above, please provide the contact name, address, phone & any other applicable info or instructions here.)

Will you require us to divide the Cremated Remains?

Yes

If 'Yes', how many portions are needed and how much in each portion?

(i..e. - equal portions: divide in half/thirds/fourths | divide in half & split 1 half into 2 equal portions | take out 2 portions of 1/2 a cup each | etc.)

Additional Disposition Info

(Please provide any other details, special instructions or preferences regarding the disposition of the cremated remains)

Would you like to put aside any funds towards the cost of any certified copies of the death certificate?

*1 copy is included in the Simple Cremation Packages | *6 copies are included in the Premium Cremation Packages. (Additional copies through us are currently $12/copy; this would be a cash advance item & price is subject to change. Funds paid towards death certificates can be trusted at the current rate & any difference in price at time of death would be due. Or you could set aside additional funds for this if you'd like to cover any price increases.)

Yes

# of copies with the Cause of Death?

(SEE NOTATION FROM FL HEALTH DEPT. BELOW REGARDING WHO CAN RECEIVE)

# of copies without the Cause of Death?

**Cause of death is confidential and only available to certain people; only the following people related to the decedent (person who died) may receive them: SPOUSE, CHILD, PARENT, GRANDCHILD, SIBLING, and any person with certain legal documentation, including: a Will pursuant to Florida Statute s.732.502 or an insurance policy or other document demonstrating his or her interest in the estate of the decedent. A copy of the legal document will need to be provided to us to send in with the order. IF THE NEXT OF KIN DOES NOT MEET ONE OF THE REQUIREMENTS LISTED HERE, WE CAN ONLY ORDER THEM COPIES WITHOUT CAUSE

PLEASE NOTE: The cause of death cannot be included when requesting copies for probate issues. The cause of death is not needed for real estate taxes, property claims, vehicles title transfer or closing out bank accounts Life insurance often requires the cause of death

Will you require any other type of urn other than what is included in the package selected?

(1 - Black Polymer Urn included in the Simple Cremation packages | 1 - Premium Brass/Alloy/Wood Urn, up to $195 value, included in the Premium Cremation packages)

Yes

If 'Yes', what type of alternate urn you are interested in?

(If you have a specific urn in mind please specify that here or give us any descriptive info, ie - color, material, etc., that would interest you & we can provide a selection from which to choose. We will provide pricing on the urn once selected.) *Pricing for Merchandise is subject to change; funds paid towards merchandise will be trusted at today's pricing and any difference at time of death would be due.

Are there any other additional items (services, merchandise, etc.) that you would like added in to these arrangements? If so, please list below:

DEMOGRAPHIC INFO FOR THE BENEFICIARY DEATH CERTIFICATE:

Please provide current Statistical Information pertaining to the person that arrangements are being made for. This information will be verified with the Legal Next of Kin after death to record any changes that have happened after submitting this form.

If any information is not known or cannot be acquired please enter “Unknown”

NAME (First, Middle, Last, Suffix)

SEX

Male

Female

DATE OF BIRTH

YYYY

PLACE OF BIRTH

City and State or Foreign Country

SOCIAL SECURITY NUMBER

RESIDENCE - Street Address

(Specify current residence address for the person that arrangements are being made for)

RESIDENCE - City

RESIDENCE - County

RESIDENCE - State

RESIDENCE - Zip Code

MARITAL STATUS

Divorced

Married

Married, but Separated

Married, simultaneous death

Never Married

Unknown

Widowed

SURVIVING SPOUSE'S NAME (First, Middle, Last)

SURVIVING SPOUSE'S MAIDEN NAME (if wife)

Enter Last Name before first marriage

USUAL OCCUPATION

DO NOT USE "RETIRED" OR "DISABLED" (indicate type of work done during most of the working life, even if they only worked for 1 day) Disabled can only be used if the person was disabled their entire life from birth & never worked a single day Homemaker can be used for anyone that only worked within the home

KIND OF BUSINESS/INDUSTRY

Do not use a company name

Race - Other

(Please specify what Native Tribe, Other Asian, Other Pacific Islander, or Other if selected above.)

Hispanic or Haitian Origin?

(Specify if the person was of Hispanic or Haitian Origin)

Mexican

Puerto Rican

Cuban

Central/South America

Haitian

Other Hispanic (specify below)

Unknown

Other Hispanic Origin

EDUCATION

(Specify the highest degree or level of school completed to date)

Ever in U.S. Armed Forces?

Yes

Unknown

If 'Yes', Branch of Service

FATHER'S NAME (First, Middle, Last, Suffix)

(if unknown type 'Unknown')

MOTHER'S NAME (First, Middle, Last)

DECEDENT'S MOTHER'S MAIDEN NAME

Enter Last Name before first marriage. The State requires this information if known; if not known please type "Unknown"

INFORMANT INFO:

INFORMANT'S NAME (First, Middle, Last, Suffix)

(name of the person providing this information for the death certificate)

INFORMANT'S RELATIONSHIP

(If making arrangements for yourself select "Self", otherwise specify if you are the spouse, son, daughter, mother, father, brother, sister, etc. of the person you are making arrangements for)

INFORMANT'S RELATIONSHIP - OTHER

(If "Other" was selected above, please specify your relationship to the person that arrangements are being made for)

INFORMANT'S STREET ADDRESS (mailing)

INFORMANT'S CITY / TOWN

INFORMANT'S STATE

INFORMANT'S ZIP CODE

INFORMANT'S PHONE #

(###)

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INFORMANT'S PHONE TYPE

Please specify the type of phone this is:

INFORMANT'S EMAIL ADDRESS

Would you like to receive status updates and other communications by:

(any documents that we provide for review or signature will be sent via email; please check your email regularly during this process)

LEGAL NEXT OF KIN/SURVIVORS

(Please specify who will be the legal next of kin upon death. It is possible that some information above may change between the time arrangements are made & death occurs so we will need a list of people we may contact to confirm the death certificate information. Please provide a list of current survivors with their names and contact info so we have a list of relatives and/or friends to contact after death.)

ADDITIONAL INFORMATION OR INSTRUCTIONS

(Please provide any other additional info or instructions not covered above or state any questions you may have here.)

How did you hear about us?

Acknowledgement

By checking here, I acknowledge that all information is correct to the best of my knowledge & this form is for informational purposes only. Full arrangements will be made with a licensed staff member.

By checking here, I acknowledge that the pricing listed on this form is our current pricing only & submission of this form does not guarantee any pricing listed here. To guarantee any services price, a Pre-Need contract must be executed & pre-payment be made. If no contract is executed we can hold the demographic information & selection preferences regarding services but any future changes in pricing will apply when death occurs.

Thank you! We will be in touch if we have any questions on the information submitted.

Pre-Need Service & Death Certificate Info Form

Please complete the service information & required demographic information for the Death Certificate below: