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Information Form

If a Death Has Just Occurred

We are very sorry for your loss and stand ready to assist you in your time of need. If you have not already done so, please ask your health provider or first responder to notify us of your loved one’s death, or you may call us now.

You are welcome to send us information using the form below. We understand that you may not have access to all the details below (or would prefer to provide in person). You are welcome to fill out as much or as little as you prefer. We will cover the remainder when we meet with you.

Arrangement Information

Field label

Personal Information of Deceased

Last Name:

First Name:

Middle Name:

Date of Birth:

Date of Death:

Time of Death:

Free Text

Field label

Preparation Information

Has a Doctor / Coroner Been Notified?

Yes

Has the Body Been Released for Removal?

Yes

If deceased passed at home

Enter your free text here

Do You Permit Us to Cremate the Body?

Yes

If Yes, Who has Granted Permission?

Free Text

Physician Information

Name of Doctor Signing Death Certificate:

Street:

City

State/Province

ZIP/Postcode:

Business Telephone:

Email Address:

Free Text

Personal Information of Person Legally Responsible for Disposition

Last Name:

First Name:

Middle Name:

Relationship to Deceased:

Street:

City:

State/Province:

ZIP/Postcode:

Primary Phone Number:

Secondary Phone Number:

Best Time to Reach:

Via phone

Enter your free text here

Do you have a Prearrangement on file with us

Yes

If Yes, Under What Name?

Information Form

If a Death Has Just Occurred

Arrangement Information

Assurance Cremation Society

365 Days of Grief Support

Information Form

If a Death Has Just Occurred

Arrangement Information

Assurance Cremation Society

365 Days of Grief Support

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