At-need Information Form | Glunt Funeral Home

Does the Decedent have a Prearrangement on file with us?

Information About the Decedent

Information About the Decedent

First Name:*

Middle Name:

Last Name:*

Maiden Name (if applicable):

Nickname:

Names the Decedent May Also Have Gone By:

Gender:

Last Permanent Address

Last Permanent Address

Street:

City:

State/Province:

Zip/Postcode:

Is the address in the City or Borough limits?

Yes

No

Not Sure

If NO, which Township?

Place of Death

Place of Death

Date of Death:

If Death Occurred in a Hospital:

Which Hospital?

If Death Occurred Somewhere Other Than a Hospital:

Specify Address or Facility

Additional Information about the Decedent

Additional Information about the Decedent

Date of Birth:

City of Birth:

State of Birth:

Social Security Number:

Ethnic Origin:

Specify Other Ethnic Origin:

Education

Education

Highest Level of Education:

High School and/or College(s) Attended:

Occupation

Occupation

Decedent's Usual Occupation:

Type of Industry:

Work History:

Were They Retired?

Hobbies, Interests, Clubs and Associations

Hobbies, Interests, Clubs and Associations

Please list any Interests or Hobbies they had:

Please list any Clubs, Associations or Orders this person was involved in:

Family Information of the Decedent

Family and Relatives of the Decedent

Are you the Person Taking Charge of Funeal Arrangements?

Are you the Person Taking Charge of Funeral Arrangements?

Are you the Person Taking Charge of Funeral Arrangements

Yes, I will be taking charge. (Skip to Marital Status)

No, I will not.

Unsure at this time.

Name of the Responsible Individual

Relationship of Responsible Person

Best Phone # of Responsible Person

Email Address of Responsible Individual

Spouse of the Decedent

Marital Status

Marital Status:

Spouse's - First Name:

Spouse's - Middle Name:

Spouse's - Current Last Name:

Spouse's - Maiden Name (If applicable):

Spouse's Date of Birth:

Spouse's - Social Security Number:

Spouse's - Phone Number:

Spouse's - Address:

Specify Other Address of Spouse (Number & Street, City, State & Zip)

Parents of the Decedent

Parents of the Decedent

Father's Full Name:

Father Living/Deceased

Living

Deceased

Unknown

Mother's Full Name:

Mother's Maiden Name:

Mother Living/Deceased

Living

Deceased

Unknown

Children of the Decedent

Children of the Decedent

Living Sons:

Deceased Sons:

Living Daughters:

Deceased Daughters:

Other Members of the Family

Other Members of the Family

Living Brothers:

Deceased Brothers:

Living Sisters:

Deceased Sisters:

Living Grandchildren:

Deceased Grandchildren:

Living Great- Grandchildren:

Deceased Great-Grandchildren

Other Living Relatives or Special Individuals

Other Deceased Relatives or Special Individuals

Funeral Service Choices

Funeral Service Choices

Depending on the schedule of the funeral home, not all dates may be available for visitation or calling hours.

Visitation Options

**NOTE - Visitation Dates and Times are contingent upon the schedule of the Funeral Home and/or Church or Minister.**

Would you like to have Visitation?

If Yes, is there a certain date you would like to have Visitation?

Preferred Times for Visitation:

Funeral or Memorial Service

Funeral or Memorial Service Options

**NOTE - Funeral Service Dates and Times are contingent upon the schedule of the Funeral Home and/or Church or Minister.**

Would you like to have a Funeral or Memorial Service?

If yes, is there a certain date you would like to have the Service?

Preferred Time for Service:

Other Funeral Service Options

Other Funeral Service Options

Please list any Musical Selections this person would like to include in their Services:

Please list any Special Themes this person would like to include in their Services:

Please list any Poems, Religious Text, or Readings this person would like to include in their Services:

Is there a Special Story, Personal Thank You, or Message of Hope this person would like to be read during their services?

Religion

Religious Affiliation

Did they have a religious affiliation?

Yes

No, (skip to next section)

Unknown, (skip to next section)

Have you already made contact with a minister?

Preferred Minister:

Church they are affiliated with:

Phone # (If known)

Final Disposition

Final Disposition

What would you like the Final Disposition to be?

Do they have Cemetery Lots:

Cemetery Name:

Veteran

US Military Service Information

Was the Decedent or their Spouse in the US Armed Forces?

Branch of Military:

Do you have a copy of the Veterans Military Discharge paperwork (DD-214)?

Yes, we do and will provide a copy to the funeral home

No

Unknown

Physician Information

Physician or Hospice Information

Was the decedent under doctors care? (within the last few weeks or months)

Yes

No

Unknown

Name of Primary Care Doctor:

Phone #:

Was the decedent in a Hospice program?

Yes

No

Unknown

If yes, which Hospice program?

Free Text

Obituary

Would you like assistance in writing an Obituary for the Decedent?

Free Text

Contact Information

Information about the person who filled out this form:

First Name*

Last Name*

Relationship to Decedent*

Address*

City*

State/Province*

Zip/Postcode*

Primary Phone Number*

Secondary Phone Number

Best Time to Reach Via Phone*

Email Address:*

Online Arrangement Form

If a Death Has Just Occurred

An At-Need Informational Guide to help plan a funeral

Online Arrangement Form

If a Death Has Just Occurred

An At-Need Informational Guide to help plan a funeral

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