Service Options At Need Information

At Need Information

At-Need Information Form
Thanks for taking the time to fill out the At Need Planning Form. By completing the following information at your own convenience, you should find it easier to provide correct information and have some time to think about the type of services you desire.

The information provided on this form will help the memorial home complete the death certificate and other required documents. In addition, this information will assist the funeral director to better understand your initial wishes. Relaying required statistical information can be time consuming. Our desire is to help expedite the final arrangement conference at the memorial home and make the process a little more comfortable.

Please complete (as much as possible) the information on the form and select Submit Information at the end to email to the memorial home. You may also print out the form and bring it with you to the arrangement conference or fax.

If you have any questions, please contact the memorial home at any time. Thanks again for helping us serve you more efficiently.


Deceased Information
Last Name:
First Name:
Middle Name:
Sex:
Race:
Date of Birth: / /
Place of Birth: City

State

OR Country
Date of Death: / /
City of Death:
State of Death:
County of Death:
Location of Death:
If other, please indicate address:



Name of the Place
of Death:
Social Security #:
Education
Usual Occupation:
(most of life)
Kind of Business:
Company: (optional)
Marital Status:
Surviving Spouse:
If wife, provide
maiden name:
Residence:
(street Address)
City/Town:
Inside City Limits:
County:
State:
Zip Code:
Length of Residence
in County:
Fathers Full Name:
Mothers Full
Maiden Name:

Type of Disposition
Disposition will be:
          
If Cremation, disposition of ashes?:
          
Name of Cemetery (if applicable):
          
City:
State:

Preparation and Viewing
Preparation and Viewing
Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the memorial home needs authorization from the next of kin for embalming.

Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, Pennsylvania State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.

The family preference regarding viewing/embalming is:
          
I authorize Danjollell Memorial Homes & Crematory to embalm:
          
Name of authorizing person:
Relationship to deceased:

Veteran Information
Was Decendent ever in the US Armed Forces?:
       YES NO (if no, continue to next section)
Branch of Service:
Date Enlisted: / /
Date Discharged: / /
Honorable Discharge: YES NO
Military Serial #:
Is copy of discharge papers available?
       YES NO (if yes, please bring for us to copy.)

Informant Information
Name of person in charge:
Relationship to deceased
Address:
City
State Zip
Phone #:
Email:

Funeral and Memorial Service Information
Preferred Place of Service:
Religious Denomination (optional):
Is there Pre-Need Funeral Insurance on decedent?: YES NO
If yes, specify type:
(i.e. Forethought, Purple Cross, trust, etc.)

Special Instructions
Note: Use box below to indicate any additional information that may be helpful at this time. Other details regarding services, merchandise, flowers, financing, etc., will be discussed and finalized at the arrangement conference.



PLEASE CALL FOR AN APPOINTMENT.

Thank you for completing our online arrangement form.



About Us
General Information
Services
Cremation Services
Merchandise
Pre-Arrangement
Grief Resources
Flower Shop
Obituaries
© 2003 D'Anjolell Funeral Home and FuneralNet 

main | about us | general info | our services | cremation services | merchandise
pre-arrangement | grief resources | flower shop | obituaries