Online at Need Form

Deceased's Vital Statistics for Death Certificate

First Name

Middle Name

Last Name

SexMaleFemale

Race

Date of Birth

Month

Day

Year

City of Birth

State of Birth

Country of Birth

Date of Death

Month

Day

Year

City of Death

State of Death

Country of Death

Location of Death

If Other, Please Indicate Name of Place and Address

Education

Occupation (most of life)

Kind of Business

Employer

Marital Status

Full Name of Surviving Spouse (if applicable)

Maiden Name (if wife)

Residence

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Length of Residence in Country

Father's Full Name

Mother's Full Name

Type of Disposition

Disposition Will Be

If Cremation, Indicate Preference for Disposition of Ashes

Name of Cemetery (If Applicable)

Address of Cemetery (If Applicable)

Preparation and Viewing

Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming. Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.

Family Preference Regarding Viewing/Embalming Is:

Name of Authorized Person

Relationship to Deceased

Veteran Information

Branch of Service

Date Enlisted

Month

Day

Year

Date Discharged

Month

Day

Year

Honorable Discharge?YesNo

Military Serial Number

Is Copy of Discharge Papers Available?YesNo(If yes, please bring to us to copy.)

Your Contact Information

First Name

Last Name

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Relationship to Deceased

Funeral/Memorial Service Information

Preferred Place of Service

Religious Denomination

Is There At Need Funeral Insurance on Decedent?

If Yes, Specify Insurance Type: (i.e., Forethought, Purple Cross, trust, etc.)

Other Information & Instructions

Online at Need Form

Deceased's Vital Statistics for Death Certificate

Residence

Type of Disposition

Preparation and Viewing

Veteran Information

Your Contact Information

Funeral/Memorial Service Information

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Eastside Chapel

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