Immediate Need

If A Death Has Just Occurred

Immediate Need Form

Free Text

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:

Free Text

EDUCATION

School Name:

Highest Level of Education:

School Location:

Free Text

WORK HISTORY

Occupation:

Company Name:

Years at Company:

Free Text

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?

Free Text

PHYSICIAN INFORMATION

Name of Doctor Signing Death Certificate*

Business Telephone

Street Address

City

State

Zip Code

Free Text

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

Do you have arrangements on file with us?

If Yes, Under What Name?

Get in Touch

If A Death Has Just Occurred

Immediate Need Form

Thomas E. Melvin & Son Funeral Home, Inc.

A Year of Grief Support