Register With Us for Your Cremation Request

Registration is the second step in our three-step cremation process. By completing the registration form you are giving us the information that we need to handle the cremation arrangements. The form contains confidential and private information. Because we use this information to complete the death certificate, notify social security and secure the necessary authorizations and permits it is necessary that we have the form completed accurately and in it’s entirety. If you are pre-planning for someone, we encourage you to complete the form in it’s entirety to assist your family in making arrangements when our services are needed.

FULL LEGAL NAME OF PERSON TO BE CREMATED:*
First Middle Last Suffix
MAIDEN NAME:
GENDER:*
RACE:*
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 State ZIP Code
RESIDENCE INSIDE CITY LIMITS?*
COUNTY OF RESIDENCE:*
Example: Tarrant, Dallas, Denton, etc.
DATE OF BIRTH:
Date Format: MM slash DD slash YYYY
PLACE OF BIRTH:*
City State / Province / Region 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:*
SPOUSE'S FULL NAME:*
First Middle Last Suffix
SPOUSE'S MAIDEN NAME:*
IF NONE, TYPE: N/A
FATHER'S FULL NAME:*
First Middle Last Suffix
MOTHER'S FULL NAME:*
First Middle Last Maiden
HIGHEST LEVEL OF EDUCATION COMPLETED:*
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:*
PEACE OFFICER:*
Ever a peace officer in the State of Texas?
INFORMANT:*
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.
INFORMANT'S RELATIONSHIP:*
Your relationship to the person you are planning for
I AM PLANNING FOR:*
INFORMANT'S ADDRESS:*
Street Address City 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?
NEXT OF KIN'S ADDRESS:
Street Address City 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.
NAME 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.

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