Place of Disposition if Cremation was NOT Selected

Please specify either the cemetery name with city & state (for burial, entombment or removal from state) OR the anatomical donation company/facility name with city & state

Other Services Not Listed Details:

(If none of the above options apply, please state your preference for the type of services desired)

Other Disposition

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

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.)

If 'Yes', please let us know what type of alternate urn you are looking for:

You can also review our available urn options at www.oururncatalog.com

Provide any applicable Info for additional merchandise/services selected above:

(ie - number of prayer or acknowledgement cards needed, number of memorial folders needed, type of alternate or keepsake urn or jewelry you are looking for, etc.)

DEATH CERTIFICATES (certified copies)

# 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 YOU DO NOT MEET ONE OF THE REQUIREMENTS LISTED HERE, WE CAN ONLY ORDER YOU 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

DECEDENT INFO (Demographics of the Deceased for the Death Certificate):

In this section, please provide the information requested regarding the Deceased person. These are state mandated questions required to complete the death certificate. If any of the information is not known or cannot be acquired, please enter "Unknown".

DECEDENT'S FULL NAME BELOW:

**MUST BE THEIR CURRENT LEGAL NAME THAT MATCHES THE NAME ON THEIR SOCIAL SECURITY CARD TO PASS THE SYSTEM VERIFICATION WITH THE SOCIAL SECURITY ADMIN**

DECEDENT'S FIRST NAME

DECEDENT'S MIDDLE NAME OR MIDDLE INITIAL (if applicable)

DECEDENT'S LAST NAME

DECEDENT'S SUFFIX (ie - Jr, Sr, II, III, etc; if applicable)

AGE of Decedent

PLACE OF BIRTH of Decedent

City and State or Foreign Country

SOCIAL SECURITY NUMBER (for decedent)

RESIDENCE - Street Address (for decedent)

RESIDENCE - City (for decedent)

RESIDENCE - County (for decedent)

RESIDENCE - State (for decedent)

RESIDENCE - Zip Code (for decedent)

RESIDENCE - Country (for decedent)

(If Not USA, please change to appropriate country)

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

SURVIVING SPOUSE'S MAIDEN NAME (if wife)

Enter Last Name before first marriage

DECEDENT'S 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

Decedent's Race - Other

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

Other Hispanic Origin

DECEDENT'S EDUCATION

(Specify the decedent's highest degree or level of school completed at time of death)

If 'Yes', was death service related?

If 'Yes', Branch of Service

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

(if unknown type 'Unknown')

DECEDENT'S MOTHER'S NAME (First, Middle, Last)

(please include maiden name if known)

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"

DATE AND PLACE OF DEATH INFO:

PLACE OF DEATH - Other (description)

If "Other" was selected above please specify here

PLACE OF DEATH - Facility Name (if not listed) or Address

(street address of place of death or facility name if not in above list)

COUNTY OF DEATH

CITY of Death

ZIP CODE of Death

INFORMANT AND DOCTOR INFO:

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

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

INFORMANT'S RELATIONSHIP TO DECEDENT

(specify if you are the spouse, son, daughter, mother, father, brother, sister, etc.)

INFORMANT'S RELATIONSHIP - OTHER

(If "Other" was selected above, please specify your relationship to the deceased)

INFORMANT'S STREET ADDRESS (mailing)

INFORMANT'S CITY / TOWN

INFORMANT'S STATE

INFORMANT'S ZIP CODE

INFORMANT'S COUNTRY

(If Not USA, please change to appropriate country)

INFORMANT'S PHONE TYPE

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)

INFORMANT'S SOCIAL SECURITY NUMBER

(This info will only be used on the Statement of Goods & Services)

If "No", Specify Legal Next of Kin & Contact Info (name, phone, email, address, etc.)

(Please specify who the legal next of kin is, if other than you, the Informant. Please provide their name and contact info as they will need to sign the Cremation Authorization. If more than one person exists with the same level of authority, please list them all, i.e. - children, siblings, grandchildren)

If "No", Specify who will be financially responsible and provide contact information for them:

Name, Phone #, Email Address, Mailing Address (any contact info you have)

Physician's Name (if known)

(Attending or other Doctor to sign the death certificate)

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?

Service & Death Certificate Info Form

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