Deceased
Name:
Case
Id:
Dat
e of Birth:
Dat
e of Death:
Tim
e of Death:
Age
: Yrs.
Mos
.
Day
Hrs
Min
Confidential:
Yes
No
Deceased BIO Information
Physicians/Funeral Directors
Funeral Arrangements
Education/Ethnic
Cause Of Death
Expenses
Edit Deceased BIO
Salutation:
Fir
st Name:
Mid
dle Name:
Las
t Name:
Suf
fix:
If Female:
Maiden Name:
Add
ress 1:
Add
ress 2:
Cit
y:
City is a Township/City
City
Township
Unknown
State:
Zip
Code :
Cou
nty:
Soc
ial Sec.:
Occ
upation:
Bus
iness:
Residence Inside City/Township
Yes
No
Unknown
SEX
Male
Female
Unknown
Hispanic Origin
Yes
No
Unk.
Fai
th:
Ethnic Origin
Choose Ethnic Ori
gin:
Ethn
ic Specify:
(Name of the enrolled or principal
Tribe):
Birth Information
Cit
y of Birth:
Cou
nty Of Birth:
Sta
te or Country of Birth:
Place of Death Information
Select
Place of Death:
Hospice?
Yes
No
If Facility (select):[Institute]
If
Other, Specify Specific Location:[specifystreetfacility]
If
Other, Specify The Street:[institute]
Cit
y:
State:
Alternate State:
Zi
p:
DC
Cost 1:
DC
Cost 2:
County
Was death inside city limits
Yes
No
Unknown
Fac
ility Notes:
Select a Relation to Edit or Choose Add
Add New Relation
Edit A Relation
Rel
ationship:
Living
Yes
No
Salutation:
Fir
st Name:
Mid
dle Name:
Las
t Name:
If
Female - Maiden Name:
Add
ress 1:
Add
ress 2:
Cit
y:
Sta
te:
Zip
Code :
Soc
ial Sec.:
Hom
e Phone:
Wor
k Phone:
Cel
l Phone:
Sec.
Education:
College
Education:
HISPANIC ORIGIN
Yes
No
Unknown
Choose Relation Ethnic:
Or
Ethnic Specify:
Informant
Bill To
Survivor
Responsible
Person Authorizing Service
Beneficiary
VA Claimant
VA Claimant Line 6
Monument Applicant
Prepaid Rcvr. of Monument
Use For QB
If Plot/Interment Expenses are Unpaid, will file claim for Expenses?
Flag Applicant
Receive Flag
Created in AtNeed
Created in PreNeed
DC Applicant
DC Applicant Receiver
Print DC Applicant
Relationship of Applicant to Deceased
Family:
Legal Rep of Family Member:
Not Related:
Need For Copy: (if not a family member or legal representative):
Remove Case
DC
Vet.
Emb.
Payments
Reports
Letters
Save All
Autopsy?
Was an autopsy performed?
Was autopsy considered in cause of death?
Was Coroner Notified/Case Referred?
Attending ?
Attending Physician:
Medical Examiner:
Coroner:
Pronouncing and Certifing Physician:
Select Physician ?
Select Physician or Enter Manualy:
Add
ress:
Spe
cial Requirements:
Certifier ?
Certifying Physician:
Medical Examiner:
Coroner:
Pronouncing and Certifing Physician:
Declined:
Select Certifier ?
Select Certifying Physician or Enter Manualy:
Add
ress:
Spe
cial Requirements:
Funeral Home Information ?
Select Funeral Director or Enter Manualy:
Dir
ector License:
Select an Embalmer or Enter Manualy:
Emb
almer License:
Select a Funeral Home:
Funeral Home Cit
y:
Sta
te:
Funeral Home Lic
ense:
Funeral Home Lic
ense:
Remove Case
DC
Vet.
Emb.
Payments
Reports
Letters
Save All
Final Disposition
Burial
Removal from State
Donation
Cremation
Other
Entombment
Hospital
Resomation
Specify Disposition ?
Select Cemetery
Cemetery Name:
Addr
ess 1:
Addr
ess 2:
City
State
Zip
Cemetery Directions and Notes
Blo
ck:
Section:
Sectio
n Number:
Lot Num
ber:
Gra
ve:
Per
mit:
Cem. Contract Date:
Service Information
Service Type:
Normal ServiceType
Ship In/Ship Out
Trade Call
Cremation
Normal Service Type
Service
Place:
Serv
ice Address:
Serv
ice Date:
Service t
ime:
Ship In or Ship Out Service Type
Remove Shipper:
Add Shipper:
Company:
Contact:
Address:
Address 2:
City:
State:
Zip:
Phone:
ext.:
Add Carrier:
Edit Carrier
Trade Call
Add New Trade Call
Trade Call:
Contact:
Address:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Directions:
Section 1, 2 and 3 - Processing Decedent's Remains by Crematory
Special Handling/Implants/Coroner/Certifier
Cremation Reporting
Section 0 - Receipt of Human Remains
Cremation Certificate:
Schedueled Date:
Schedueled Time:
Special Charges
Hospice?
Yes
No
Place Of Death:
Street:
City:
State:
Zip:
Section 1 - Receipt and Identification of Decedants Human Remains by Crematory
Individual Confirming Identity of Decedent and Address
Crematory Licensee Name Receiving Remains
Add/Change
Decedant Delivered to Crematory Date
Decedent Delivered to Crematory Time
Decedent Delivered By
Affilliated With
Add/Change
Delivery Container
Received By
Section 2 - Record of Decedants Cremation by Crematory
Decedent Placed In Cremation Chamber Date
Decedent Placed In Cremation Chamber Time
Decedent Placed In Cremation Chamber By
Decedent Retrieved From Cremation Chamber Date
Decedent Retrieved From Cremation Chamber Time
Decedent Retrieved From Cremation Chamber By
Cremated Remains Processed Date
Cremated Remains Processed Time
Cremated Remains Processed By
Type of Container Cremains Placed In
Urn Shippable?
Yes
No
Section 3 - Delivery Of Decedant's Cremated Remains From Crematory
Released/Delivered Date
Released/Delivered Time
Person Who Delivered Remains
Delivered By:
Receiver Affiliated with a Funeral Home
Received By:
Affiliated With:
Add/Change
Receiver Is An Individual
Remains Delivered To:
Adderess Where Delivery Took Place
Address Where Delivery Took Place
Medical Examiner Authorization Required?
Personal Property Handling
Personal Property:
Special Handling?
Describe:
Death Due To Infectious Disease?
Infectious Disease?
Deliver To Cemetery?
Deliver To Cemetery?
Add/Change Cemetery
Release to Relation?
Select:
Scattering at Sea by Funeral Home or Funeral Home's Agent?
Agent:
Ship Via Mail:
Yes
Address 1:
Address 2:
Other Disposal:
Yes
Disposal 1:
Disposal 2:
IMPLANTS
Radioactive Implant:
Yes
Implant Date:
Describe:
Disposition:
Mechanical Implant:
Yes
Describe
Disposition
:
Describe
:
Disposition
:
The Deceased’s remains (DO or DO NOT) contain a pacemaker or any other material or implant which may be hazardous to, or cause damage to, the cremation chamber or the person performing the cremation.
Do
Do Not
Coroner
:
Coroner Address
:
Coroner County
:
Coroner State
:
Certifier
:
Viewing and Visitation Information
Viewing Where:
Viewing Date:
Viewing time:
Family Present:
Wake Visitation:
Address of Wake/Visitation:
Viewing Date:
Viewing Time:
Service Attendants(From Funeral Home):
Clear Attendants
Officiating Or Clergy:
Clear Clergy
In Lieu of Flowers:
Remove Case
DC
Vet.
Emb.
Payments
Reports
Letters
Save All
EDUCATION
8th Gradeor Less
9th/12th Grade No Diploma
High School Graduate or Ged Completed
Some College Credit but no Degree
Asociate Degree (e.g., AA,AS)
Bachleors Degree (e.g.,BA,AB,BS)
Masters Degree (e.g.,MA,MS,Meng.,MED,MSW,MBA)
Doctorate (e.g.,PHD,EDD) or Professional Degree
HISPANIC ORIGIN
No, Not Spanish/Hispanic/Latino/Latina
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Some College Credit but no Degree
Yes, Other Spanish/Hispanic/Latino/Latina (specify)
MARITAL STATUS
Married
Married but Seperated
Widowed
Divorced
Never Married
Unknown
Remove Case
DC
Vet.
Emb.
Payments
Reports
Letters
Save All
Additional Death Certificate Information
Cause of Death
Natural:
Accident:
Suicide:
Homicide:
Could Not be determined:
Pending Investigation:
Leave Blank:
Did Tobacco Use Contribute To Death?
Yes:
No:
Probably:
Unknown:
Was Deceased Female
Not pregnant in last year
Pregnant at Time Of Death
Not Pregnant at Time Of Death but was Pregnant Within 42 days:
Not Pregnant at Time Of Death but was Pregnant Within 43 days and 1 year:
Unknown If Pregnant Within Past Year:
Check cause for filing provisional death certificate
Clear:
1. Physician unavailable due to illness:
2. Coroner unavailable due to illness:
3. Physician unavailable due to absence from community:
4. Coroner unavailable due to absence from community:
5. Autopsy or chemical Biological examination results pending:
6. Death Certificate provided to physician sinature deferred:
Injury
Date of Injury:
Time of Injury:
Injury at work:
Remove Case
DC
Vet.
Emb.
Payments
Reports
Letters
Save All
Reset Funeral Template
Selected Funeral Template:
Contract Date:
Professional Services and Equipment
Merch/Cash Advances
Payments/Refunds
Adjustments
Income Sources
DC Dispersal
ContractDetail
Delete Invoice on QB
1. CHARGES FOR PROFESSIONAL SERVICES SELECTED
2. CHARGES FOR FACILITIES AND STAFF
3. OTHER SERVICES/FACILITIES/EQUIPMENT
Total of Equipment:
4. CHARGES FOR AUTOMOTIVE EQUIPMENT
5. OTHER SERVICES/FACILITIES/EQUIPMENT
EXTENDED CHARGES FOR AUTOMOTIVE EQUIPMENT
Number and Cost of Vehicle 1
Cost Each
Number
Total Charges
Number and Cost of Vehicle 2
Cost Each
Number
Total Charges
Milage Outside
Mile Radius
Vehicle(s)
Miles Traveled
Milage Charges
Total Milage Charges
TOTAL OF SERVICES SELECTED
Total of Services Selected
B. Merchandise Selected
P/O
Qty:
Merchandise:
Merchandise Item:
Company:
Cost..
Sales Price..
C. Cash Advances
Add Publisher:
Edit Obitituary Publisher
Select Cash Advances
Taxable
Cash Advance:
Cost..
Qty:
Discount if Offered:
Total Cash Advance:
Remove Case
DC
Vet.
Emb.
Reports
Letters
Save All
Date/Time Popup
×
Please enter here:
Departure Date:
Departure Time:
Arrival Date......:
Arrival Time......: