1

Please provide the following information for the deceased. Please put unknown if you do not know the information being requested. 

 *

Please provide the following information for the deceased. Please put unknown if you do not know the information being requested.

First and Last Name: *	Social Security Number: *	Date of Birth: *
Date of Death: *	Address: *	County of Death: *
Current location of body: *

2

For Funeral Homes:
If this form is being completed by funeral home staff, please provide the pick up location and the name and phone number of the person who called the funeral home for pick up

For Funeral Homes: If this form is being completed by funeral home staff, please provide the pick up location and the name and phone number of the person who called the funeral home for pick up

Pick up location of deceased:

Name:

Phone number:ext.

3

How did you hear about us? 

 *

How did you hear about us?

Family/Friend	Funeral Home	Medical Examiner
Hospital	Internet Search	Other: If other, type text here.

4

Please select the deceased's marital status.

 *

Please select the deceased's marital status.

Legally Married	Widowed	Legally Divorced	Separated
Cohabiting	Single	Unknown

5

Is the deceased a Veteran? 

 *

Is the deceased a Veteran?

Yes

No

Unknown

6

Do you have a copy of the deceased's identification or driver's license? This will expedite the application process.

 *

Do you have a copy of the deceased's identification or driver's license? This will expedite the application process.

Yes

No

7

Was the deceased's death a result of a car accident or a crime?

 *

Was the deceased's death a result of a car accident or a crime?

Yes

No

8

Please list all vehicles owned by the deceased or their spouse. 

 *

Please list all vehicles owned by the deceased or their spouse.

9

Please list the cash value of all checking and/or saving accounts in the deceased's name or their spouse.

 *

Please list the cash value of all checking and/or saving accounts in the deceased's name or their spouse.

10

Please list the cash value of all IRA's, stocks, bonds and/or 401Ks in the deceased's name or their spouse.

 *

Please list the cash value of all IRA's, stocks, bonds and/or 401Ks in the deceased's name or their spouse.

11

Did the deceased receive social security benefits? 

 *

Did the deceased receive social security benefits?

Yes

No

Unknown

12

Did the deceased have a life insurance policy? 

 *

Did the deceased have a life insurance policy?

Yes

No

Unknown

13

Please provide the following information for the deceased's next of kin. Please put N/A if there is no known next of kin. 

 *

Please provide the following information for the deceased's next of kin. Please put N/A if there is no known next of kin.

First and Last Name: *	Phone Number: *ext.
Email:	Relation: *

14

Please provide your information if you are not the next of kin.

 *

Please provide your information if you are not the next of kin.

First and Last Name: *	Phone Number: *ext.
Email:	Relation: *

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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