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2. Funeral Director*
3. Funeral Home*
5. Email Address*
6. Phone*
8. Name of Deceased (First, Middle, Last)*
10. Deceased's Date of Birth*
11. Deceased's Date of Death*
13. Veteran*

    1. Yes
    2. No
14. Branch of Service (if Veteran)

    1. Army
    2. Navy
    3. Marines
    4. Air Force
    5. Coast Guard
16. Next of Kin (family contact)*
17. Relation to Deceased*
19. Next of Kin Mailing Address*
21. Address2
23. City*
24. State*
25. Zip*
27. Next of Kin Phone Number*
28. Casket or Cremation Burial*

    1. Casket
    2. Cremation
30. Date of Service Requested*
31. Day Request*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
    6. Saturday
32. Time of Service Requested*
33. Service Location*

    1. Church
    2. Funeral Home
    3. Graveside
    4. Direct Burial (No Family Present)
35. Estimated Time of Arrival to Cemetery?*
37. Oversize Casket?*

    1. Yes
    2. No
38. If Oversize, Outside Casket/Container Width
39. Outer Container*

    1. None
    2. Vault
    3. Concrete Liner
    4. Steel Liner
41. If Cremation Burial, what are the dimensions of the Urn (length, width, height?
42. Does the deceased or deceased's family have cemetery property if known, what is the name of the family member currently buried there?
44. Rules For Beautification and Improvement*

    Please Upload the signed and completed Rules for Beautification and Improvement

45. Report of Death*

    Please Upload the Report of Death

47. Additional Information
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

* indicates a required field