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Decedent’s Legal Name:

Date of Death:

Usual Residence State:

County:

Town:

Street and Number:

Apt No.:

Zip Code:

Date of Birth:

Social Security No:

Age at last birthday:

Usual Occupation:

Kind of industry:

Aliases or AKA:

Birthplace:

Education:

Ever in US Armed Forces?  Yes No

Marital/Partnership Status at time of death:

Surviving Spouse/Partner’s Maiden Name:

Father’s Name:

Mother’s Maiden Name:

Informant’s Name(required):

Relationship to Decedent:

Phone(required):

Address:

Name of Cemetery/Crematory:

Location of Cemetery/Crematory:

Date of Disposition:

Your Email(required):

Are the remains being shipped - if shipping please include name of destination (Country or State if in the US below) :

Name of Airport:

Name of Funeral home or Person Receiving Remains:

Address:

City, State & Country:

Telephone number:

Your Message/Other Information:

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