TEST cr planning form

There may be additional costs associated with the transportation of your loved one into our care. The cost, if applicable, is calculated based on the distance between the "Location of the deceased" and our facility. If the location of the deceased lies outside of the service area, the cost will be calculated in your cart. Please contact us with any additional questions.

Location of the deceased*

Location of your loved one for transportation into our care.

When do you require our services:*

I am in immediate need (a death has occurred)
I am planning ahead (I'd like to talk about pre-arranging services)

Please call us first and notify us that a death has occurred (414) 416-2041.

We extend our deepest sympathies to you for your loss. Please call us first and notify us that a death has occurred. Completing this form does not notify us immediately. After you notify us, please proceed with your online arrangements.

Do you wish to preplan for the future?

We would be honored to help you preplan services, please proceed with your online arrangements. After completing this form and finalizing your payment, please call us if you have further questions at (414) 416-2041.

The prices shown are the now current retail prices and are illustrated for the sole purpose of establishing the amount of insurance required to fund this agreement. At the time the goods and services are provided, the then current retail prices will be charged. The Party responsible for the funeral must pay any difference between the available death benefit and the then current prices, if any.

Information Form Options*

I would prefer to provide as much information now as possible.
I would prefer to provide more details later.

Information About the Person Completing This Form

First Name*

Last Name*

Phone*

Email (Important)

Person for whom I am filling for:*

If not "Myself", your relation to the deceased.

Your Address*

Street Address City State ZIP Code

Phone*

Deceased Vital Statistics for Death Certificate

Date of Death

MM

DD

YYYY

Name of Deceased*

Prefix First Middle Last Suffix

City of Birth

State of Birth

Date of Birth

MM

DD

YYYY

Gender

Marital Status at Time of Death

Name of Surviving Spouse

First Last

Father's Full Name

First Middle Last Suffix

Mother's Full Name

First Middle Last Suffix

Mother's Maiden Name

Deceased's Address

Same as my own (provided above)
Input new address

Deceased Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Residence Inside City Limits?

Yes
No

Place of Death

Other (please specify)

Education

Occupation (most of life)

Kind of Business/Industry

Deceased of Hispanic Origin?

Yes
No

Race

Veteran Information

Was Decedent Ever In the US Armed Forces?

Please list any other instruction or information you would like us to have

Name

This field is for validation purposes and should be left unchanged.

Cremation Planning Form - Copy 1

Please call us first and notify us that a death has occurred (414) 416-2041.

Do you wish to preplan for the future?

Information About the Person Completing This Form

Deceased Vital Statistics for Death Certificate

Veteran Information