St. Louis Cremation - Pre-Need Form

Date:
02/02/2012
01/29/2012
01/25/2012
01/25/2012
01/21/2012

Pre-Need Information Form	Step # 1 of 4

This information will be used for (your) 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:		Address:
Middle:		City:
*Last Name:		County:
Suffix:		State:
Date of Birth:		Postal Code:
City Of Birth:		*Phone:
State Of Birth:		Is this address in the city:	Yes No

Approximate years at current address: Under 5 5-9 10-19 20 or above

Pre-Need Information Form	Step # 2 of 4

	(give the kind of work done most of the live, DO NOT use retire, homemake is...)
Usual Occupation:
Type Of Company:
Race:
Are you hispanic:	Yes No
If yes, some text:	(Cuban, Mexican, Puerto Rican, etc.)
Highest educational level achieved:
Elementary/Secondary:	College:

Pre-Need Information Form	Step # 3 of 4

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:

Pre-Need Information Form	Step # 4 of 4

Person in charge of your arrangements - Next of Kin
First Name:		Home Address:
Middle:		Address:
Last Name:		City:
		State:
Relationship:		Postal:
		*Phone:
		Email Address:
Check if information should be mailed to Beneficiary Check if information should be mailed to next of kin
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 that this is my digital signature.
Once you have completed the Pre-Need form, please press the submit button and your information will be sent to our trusted staff. Once your information has been received, a staff member will contact you. Thank you for choosing St. Louis Cremation.

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