Immediate Need

If A Death Has Just Occurred

Immediate Need Form

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PERSONAL INFORMATION OF THE DECEASED

First Name

Middle Name

Last Name

Address of the Deceased

Was the Deceased in the Military?

If Yes, What Branch of Service?

If Yes, Do You Have DD214?

Date of Birth

Date of Death

Race or Ethnicity:

Social Security Number

Marital Status:

Spouse's Name:

Spouse's Maiden Name:

Date of Marriage:

Father's Full Name:

Mother's Full Name (Including Maiden):

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EDUCATION

School Name:

Highest Level of Education:

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WORK HISTORY

Occupation:

Company Name:

Years at Company:

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PREPARATION INFORMATION

Has the Body Been Released for Removal?

Do you permit us to embalm the body?

Do You Permit Us to Cremate the Body?

If Yes, Who Has Granted Permission?

Would you like to have the body buried?

Do you want a cemetery plot?

If Yes (to last two questions), where would you like both?

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PHYSICIAN INFORMATION

Name of Doctor Signing Death Certificate*

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IMMEDIATE FAMILY INFORMATION

Children (List Names and Relationship):

Parents (Names):

Siblings (Names and Relationship):

Grandchildren/Great Grandchildren (Names):

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PERSONAL INFORMATION OF PERSON LEGALLY RESPONSIBLE FOR DISPOSITION

First Name

Middle Name

Street Address

Last Name

Relationship to Deceased

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Best Time to Reach Via Phone

If Yes, Under What Name?

Do you have arrangements on file with us?

Get in Touch

If A Death Has Just Occurred

Immediate Need Form

Thomas E. Melvin & Son Funeral Home, Inc.

A Year of Grief Support