Cremation Registration

Please fill out the form below to send us details and vital statistics for a cremation.

1. Deceased Name *
2. Sex *
3. Date of Birth (MM-DD-YY)
5. Date of Death (MM-DD-YY)
6. Social Security Number
7. Birthplace (City and State or Foreign Country)
8. County of Death
9. Place of Death
9a. If OTHER, please specify:
10. Facility Name (If not institution, give street address)
11. City, Town, or Location of Death
11b. Inside City Limits?
12. Marital Status
13. Surviving Spouse's Name (If wife, give maiden name)
14. Residence- State
14b. County
14c. City, Town, or Location
14d. Street Address
14e. Apt. No.
14f. Zip Code
14g. Inside City Limits?
15. Deceased Usual Occupation (Indicate type of work done during most of working life.) Do not use "Retired"
15b. Kind of Business/ Industry
16. Deceased Race (Specify the race/races to indicate what deceased considered himself/herself to be. More than one race may be specified.)
 White
 Asian Indian
 Native Hawaiian
 Black or African American
 Chinese
 Guamanian or Chamorro
 American Indian or Alaskan Native
 Filipino
 Japanese
 Samoan
 Korean
 Other Pacific Isl.
 Vietnamese
 Other Asian
 Other
16b. If OTHER, please specify:
17. Deceased of Hispanic or Haitian origin?
17b. If YES, please specify:
17c. If OTHER HISPANIC, please specify:
18. Deceased Education
18b. If COLLEGE DEGREE, please specify:
19. Was deceased ever in U.S. Armed Forces?
20. Father's Name (First, Middle, Last, Suffix)
21. Mother's Name (First, Middle, Maiden Surname)
22. Informant's Name
22b. Relationship to deceased
23. Informant's Mailing- State
23b. City or Town
23c. Street Address
23d. Zip code
24. Place of Disposition (Name of cemetery, crematory, or other place)
25. Location- State
25b. Location- City or Town
Contact Phone # *
Contact Phone # *