At-Need On-line Form

Search using the deceased name or any family name for any current or past services entrusted to our firm.

AT-NEED ONLINE FORM

Making funeral arrangements at the time of loss is extremely difficult for those left behind. Our deepest condolences and blessings to the family. Making funeral arrangements at the time of a loss is very difficult.

We here at Crowe's Funeral Home, Inc. understand the emotional and financial stress involved with making funeral arrangements. Such stress can cause confusion and may affect your decision making. Allow Us To Serve You!

We will like to introduce the At-Need Online Form where you can take your time with filling in all preliminary and vital information which is half of the funeral process.

Upon reviewing all the information, the funeral director will contact you to schedule an appointment to help establish the most elegant and affordable funeral service your loved one and the family deserves.


I. Deceased Information

Deceased Full Name:
Sex:
Age:
If under 1 year:	month(s) day(s)
If under 1 day:	hour(s)
Date of Birth:	(month/date/year)
Date of Death:	(month/date/year)
Social Security Number:	(xxx-xx-xxxx)
Did deceased serve in U.S. Armed Services?
(If yes, please see Military Record)

Place of Death:
If Other, Specify
Name of Hospital or Nursing Home
Address 1:
Apt., Building, Suite, Room or Unit
City:
State:
Zip Code:

Hospice Care:
*(If Yes, please fill in all below)*
Doctor's Name:
Doctor's Address:1
Building, Room or Suite
City:
State:
Zip Code:
Phone Number:	(xxx-xxx-xxxx)

Deceased Residence
Address 1:
Apt., Building, Suite or Unit
City Name:
State:
Zip Code:

Marital Status:
Name of surviving spouse
(If wife, give maiden name)

City of Birth:
State of Birth:
Highest Education Level:

Decedent Father's Name
Decedent Mother's Name with maiden name

Last Known Occupation:
Kind of Business or Industry


II. Military Record

Branch of Service:
Serial Number:
Serial Number:
Date Enlisted:	(month/day/year)
Date of Discharge:	(month/day/year)
Rank at Discharge:
Location of a Copy of Discharge (DD214):Please bring all documentation with you
Military Honors at Graveside:
Person designated to receive flag:

Surviving Spouse Full Name:
(If wife, please give maiden name)
Spouse Social Security Number:
Spouse Address 1:
Apt., Building, Suite or Unit Number
City:
State:
Zip Code:


III. Service Preferences

Type of Service:
Preferred Time of Day for Viewing:
Preferred Time of Day for Viewing:
Preferred Time of Day of Funeral:
Preferred Time of Day of Funeral:

Casket:
(Rental Caskets are for cremation services only, Metal caskets come with sealer or non-sealer)
Person in Charge of Arrangements:
Officiating Clergy:	List Clergy Here...
Pallbearers:	List up to eight pallbearers
Flower Preference:	Enter Flower Preference...
Music Selection:	Enter Music Selection...
Jewelry: *(List all* *jewelry provided)*
Glasses:
Outer Container Preference: (for ground burial only, inquire at the funeral home)

IV. DISPOSITION

Cemetery or Crematory Name:
Location:
The cemetery property is in the name of:
Anyone interred or buried in the grave:
(If Yes, Fill in all information below)
Individual interred or buried:
Date of Death:
Section:
Grave Number:
Plot Number:
Lot:
Block:


V. INSURANCE INFORMATION

Insurance Company Name:
Phone Number:	(xxx-xxx-xxxx)
Address 1:
Room, Suite, etc.
City:
State:
Zip Code:

Policy Number(s):
List all Beneficiary(s) & Relationship

Policy Effective Date:


VI. INFORMANT INFORMATION

Informant Name/Person Handling Arrangements:
Relationship:
If Other, Please Specify:
If Other, Please Specify:

Address 1:
Apt., Building, Room, Unit or Suite:
City:
State:
Zip Code:

Home Number:	(xxx-xxx-xxxx)
Cell Number:	(xxx-xxx-xxxx)
E-mail Address:



Miscellaneous Notes and Instructions: Enter Text Here...
Yes, I agree that all the information given to the best of my knowledge is true and factual.
Sign:
Date: