Information we need to complete the death certificate and secure the necessary permits. (This information is sacred to us! We will not share with anyone.) FULL LEGAL NAME OF PERSON TO BE CREMATED:* First Middle Last Suffix MAIDEN NAME: GENDER:*Please SelectMaleFemaleRACE:*ADDRESS:*Address of residence of person to be cremated. This could be the address of a nursing home or convalescence facility if that is where the person resides/resided. Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code RESIDENCE INSIDE CITY LIMITS?*Please SelectYesNoCOUNTY OF RESIDENCE:*Example: Tarrant, Dallas, Denton, etc.DATE OF BIRTH: Date Format: MM slash DD slash YYYY PLACE OF BIRTH:* City State / Province / Region AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country SOCIAL SECURITY NUMBER (xxx-xx-xxxx):*We are required to notify social security when a death has occurred. This is also required to complete a Texas Death Certificate. NAME AS SHOWN ON SOCIAL SECURITY CARD:Oftentimes, the name that a person goes by, or what is shown on a driver's license or birth certificate, isn't the same as what is on their Social Security card.MARITAL STATUS:*Please SelectNever MarriedMarriedDivorcedWidowedUnknownSPOUSE'S FULL NAME:* First Middle Last Suffix SPOUSE'S MAIDEN NAME:*IF NONE, TYPE: N/AFATHER'S FULL NAME:* First Middle Last Suffix MOTHER'S FULL NAME:* First Middle Last Maiden HIGHEST LEVEL OF EDUCATION COMPLETED:*Please Select8th Grade or Less9th thru 12th (No Diploma)High School Graduate or GEDSome College Credit but No DegreeAssociates Degree (AA,AS)Bachelors Degree (BA, AB, BS, BBA)Master Degree (MA, MS, MENG, MEd, MSW, MBA)Doctorate (Phd, EdD) or Professional Degree (MD, DDS, DVM, LLB, JD)USUAL OCCUPATION:*The job/type of work one primarily did within a particular industry. Example: Homemaker, Teacher, Nurse, Loan Officer, Electrician, etc.KIND OF BUSINESS/INDUSTRY:*The type of industry one was involved in primarily throughout their life. Example: Domestic (Household), Education, Healthcare, Banking, Construction, etc.MILITARY:*Please SelectNo Military ServiceArmyArmy Air CorpsNavyAir ForceMarinesCoast GuardPEACE OFFICER:*Ever a peace officer in the State of Texas?Please SelectNoYesINFORMANT:*Person providing information about the deceased First Last ARE YOU THE LEGAL NEXT OF KIN?*A person's next of kin is that person's legal spouse or closest living blood relative. Please SelectYesNoINFORMANT'S RELATIONSHIP:*Your relationship to the person you are planning forPlease SelectSpouseSonDaughterParentSiblingGrandparentNiece/NephewFriendCompanion/Domestic PartnerOtherI AM PLANNING FOR:*Please SelectSomeone Who Has Just Passed AwayMyself (Pre-planning)Someone Else (Pre-planning)INFORMANT'S ADDRESS:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code INFORMANT'S PHONE NUMBER:*Enter the phone number where you can most easily be reached.INFORMANT'S EMAIL:*Enter your email and we will send you a copy of this form. Enter Email Confirm Email LEGAL NEXT OF KIN (if not the informant):*Next of kin refers to the nearest blood relative of a person, including the surviving spouse. Example: Spouse, Adult Children, Parents, Adult Grandchildren, Siblings, Grandparents, Nephew/Niece, etc. First Middle Last Suffix NEXT OF KIN'S RELATIONSHIP:*What is the next of kin's relationship to the deceased?Please SelectSpouseChildParentGrandchildSiblingGrandparentNephew/NieceAunt/UnclePower of Attorney for Right of DispositionNEXT OF KIN'S ADDRESS: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NEXT OF KIN'S PHONE NUMBER:*The phone number where this person can most easily be reached.HOW DID YOU HEAR ABOUT US?*We would love to know how you heard about our services.Please SelectGoogleYahoo/BingOther Internet SearchNewspaper/Other Print MediaHospital ChaplainHospice ReferralPersonal ReferralOtherNAME OF HOSPICE OR HOSPITAL:*The name of the hospice or hospital that referred you to us.IF OTHER, PLEASE ELABORATE:*Please be more specific on how you found out about our services.
