Immediate Need

First, let us express our deepest sympathy for your loss and know that we are here for you and your family during this difficult time.

If you've not done so, please Contact us day or night. We will make arrangements to bring your loved one into our care and will set a time for you and your family to come to the funeral home to begin the funeral arrangements.
If you would like, filling out the form below will help us gather the information we need to begin more quickly.

Immediate Need Form

Free Text

Personal Information of Deceased

Last Name*

Middle Name*

First Name*

Date of Birth*

Date of Death*

Time of Death*

Social Security Number*

Free Text

Preparation Information

Has a Doctor / Coroner Been Notified?

Yes

If Deceased Passed at Home, Do You Permit Us to Embalm the Body?

Yes

Has the Body Been Released for Removal?

Yes

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*

Email Address*

Business Telephone*

Street*

City*

State/Province*

Zip/Postcode*

Free Text

Personal Information of Person Legally Responsible for Disposition

Last Name*

Middle Name*

First Name*

Relationship to Deceased*

Street*

City*

State/Province*

Zip/Postcode*

Primary Phone Number*

Secondary Phone Number*

Best Time to Reach Via Phone*

Do You Have a Prearrangement on File with Us?

If Yes, Under What Name?

Phone:

(984) 272-7683

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