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Immediate Need
Immediate Need Form
Vital Information
Name:
Date of Death:
Address:
City Name:
State:
Zip Code:
Telephone Number:
Email:
Date of Birth:
City of Birth:
Highest Education Level:
Elementary
Secondary
College/University
Please select Grade/Years of Education Completed
0
1
2
3
4
5
6
7
8
9
10
11
12
Social Security Number:
Residence History:
Father's Name:
Father's City of Residence:
Mother's Name:
Mother's City of Residence:
Mother's Maiden Name:
Spouse's Name:
Spouse's Maiden Name:
Survivors' Names and Cities of Residence
Relatives Who Have Preceded In Death
Occupation:
Business Type:
Company Name:
Church Membership:
Lodge or Union Name:
Veteran:
Yes
No
Branch of Service:
Option 1
Option 2
Option 3
Marines
Coast Guard
National Guard
Serial Number:
Date Enlisted:
Date of Discharge:
Rank at Discharge:
Location of a Copy of Discharge (DD214):
Time of Military Service:
Not a Veteran
Peacetime
World War I
World War II
Korean War
Vietnam War
Persian War
Military Honors at Graveside:
Option 1
Option 2
Option 3
Flag Preference for Service:
None
Draped over casket
Folded on casket
Type of Service:
Chapel Service
Church
Graveside
None
Visitation Hours:
Day
Night
None
Casket:
Open for service
Closed for service
No public viewing
Person in Charge of Arrangements:
Officiating Clergy:
Pallbearers:
Flower Preference:
Music Selection:
Jewelry:
No jewelry
Give to family
Leave jewelry on
Glasses:
No glasses
Donate to lions club
Leave on
Give to family
Casket Preference:
Bronze
Copper
Stainless Steel
Steel (Sealing)
Minimum Metal
Mahogany
Walnut
Cherry
Maple
Poplar
Pine
Fiberboard / Veneer
Disposition:
Ground burial
Mausoleum
Cremation
Outer Container Preference: (for ground burial)
Bronze Triune
Copper Triune
Cameo Rose
SST Triune
Veteran
Venetian
Continental
Monticello
Minimum Grave Liner
Cemetery Name:
Cemetery Location:
The cemetery property is in the name of:
Miscellaneous Notes and Instructions:
Please send me information
Please send me information
New Field:
Please contact me to schedule an appointment
New Field:
Please contact me to schedule an appointment
Thank you for contacting us.
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Proudly Serving the Communities of Newtown, Monroe, Redding, Bethel, Danbury, New Fairfield, Brookfield, Southbury, and Surrounding Areas.
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