Immediate Need Information Form	Step # 1 of 5

This information will be used for the death certificate. Please fill in as much as possible. We need the full legal name, "William" not "Bill", and include Sr., Jr., or II, III if applicable.
* Required Information

Prefix:		Home Address:
*First Name:
Middle:		City:
*Last Name:		County:
Suffix:		State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
Date of Birth:		Postal Code:
City Of Birth:		*Phone:
State Of Birth:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY	Is this address in the city:	Yes   No
Approximate years at current address:  Under 5  5-9  10-19  20 or above

Immediate Need Information Form	Step # 2 of 5

Place of Death, or expected place of death
Home
Hospital/Nursing Home      Please Specify:
Medical Examiner
Other      Please Specify:

Immediate Need Information Form	Step # 3 of 5

	(give the kind of work done most of the live, DO NOT use retire, homemaker is...)
Usual Occupation:
Type Of Company:
Race:	Select Race White-Caucasion Black-African American Amerinca Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Guamanian or Chamorro Samoan
Are you hispanic:	Yes  No
If yes, please specify:	(Cuban, Mexican, Puerto Rican, etc.)
Highest educational level achieved:
Elementary/Secondary:	Select Twelfth Eleventh Tenth Ninth Eighth Seventh Sixth Fifth Fourth Third Second First               College:   Select 0 1 2 3 4 5+

Immediate Need Information Form	Step # 4 of 5

Mother's		Father's
First Name:		First Name:
Middle:		Middle:
Maiden Name:		Last Name:
Marital Status  Married  Never Married  Divorced  Widowed
If Married, Spouse's
First Name:
Middle:
Last/Maiden:

Immediate Need Information Form	Step # 5 of 5

Person in charge of arrangements
First Name:		Home Address:
Middle:		Address 2:
Last Name:		City:
		State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
Relationship:		Postal:
		Phone:
		Email Address:
I hereby certify that I am the nearest degree of relationship to the deceased and that I have the legal right or am charged to authorize this cremation and the disposal of the cremated remains. I understand that due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry (as well as any body prosthesis or dental bridgework), that are left with the decedent and are not removed prior to cremation will be destroyed or if not destroyed, will be disposed of by St. Louis Cremation Service. I further agree that I will indemnify and hold harmless the Cremator and Funeral Director, their officers and employees from any liability, costs, expenses or claims resulting from this authorization.
I give St. Louis Cremation authorization for cremation and I understand this is my digital signature. Once you have completed the Arrangement form, please press the submit button and your information will be sent to our trusted staff. Thank you for choosing St. Louis Cremation. To verify we have received your form, please call 314-241-8844.