At Need Arrangements Vital Statistics Form | Griffith-Cline Funeral and Cremation Services

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At Need Arrangements

We are very sorry for your loss and stand ready to assist you in your time of need. If you have not already scheduled a meeting with us, please call us on 941-748-1011.

For your convenience, we have included the following form for you to complete before arriving for your conference. We highly suggest you send us the requested information using this form. The information requested in sections A and B is used to record your loved one's passing with the State of Florida. Sections C and D will provide us with information regarding your plans for ceremonies, etc., allowing us to be better prepared for your conference. When finished, click the 'Submit Information' button below. We understand that you may not have immediate access to all of the details (or would prefer to provide in person). You are welcome to fill out as much or as little as you prefer. We will cover the remainder when we meet with you.

Vital Statistics

A. Information about the deceased

Last Name

First Name

Middle Name

Maiden Name

Sex

Father's First Name

Father's Middle Name

Father's Last Name

Mother's First Name

Mother's Middle Name

Mother's Current Last Name

Mother's Maiden Name

Decedent of Hispanic Origin?

Not Spanish/Hispanic/ChicanoMexican/Mexican-American/ChicanoPuerto RicanCubanOther specify in Comments section below

Comments

Decedent Race

WhiteBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanNative HawaiianAmerican Indian or Alaska Native specify in Comments section belowVietnameseGuamanianChamorroOther Asian specify in Comments section belowPacific Islander specify in Comments section belowOther specify in Comments section below

Comments

Date of birth

City of birthIf unable to establish City of birth at this time, please be sure to have this information available during the Arrangement Conference

OR Country if not USA

State

Date of death

City of death

State of Death

County of death

Location of death

Name of the place of death ( or street address if residence)

Location (if other)

Social Security NumberIf you choose not to provide the SS Number at this time, you must bring it with you to the Arrangement Conference.

Education

Choose highest level of education completed.

8th or less9 12 no diplomaHigh School Graduate or GED completedSome college no degreeAssociate DegreeBachelor DegreeMasters DegreeDoctorateUnknown

Veteran information

Was the decedent ever in the US Armed Forces?

YesNo

If Yes, Branch of service

Employment History

Usual occupation (most of life)

Type of business/industry

Marital Status at time of death

MarriedNever MarriedDivorcedWidowed

Surviving Spouse Name including last name prior to first marriage, if applicable.

Surviving spouse address

Street

City

State/Province

ZIP/Postcode

Informant information

Name of person in charge

Street

City

State/Province

ZIP/Postcode

Home Telephone

Cell phone

Email Address

B. Type of disposition

Disposition will be

If cremation, disposition of ashes

Anticipated Ceremonies

C. Preparation and viewing

Viewing/Embalming Preference

Open Casket Visitation (embalming required)No Viewing (embalming not required)Transportation via common carrier (i.e., air cargo embalming required)Use option required by disposition

(Unless embalming is required by the type of service chosen, remains will be sheltered in a cooler as required by Florida law.

I authorize Griffith-Cline Funeral and Cremation Services to embalm

YesNoWill advise later decision must be made within 24 hours following death

Name of authorizing person

Relationship to deceased

D. Funeral/memorial service information

Preferred place of service

Religious denomination

Are there pre-need funeral arrangements on decedent?

YesNoDon't Know

If yes, specify type if knownPlease provide contract number if possible.

Memorials & donation preferencesPlease list memorials or charitable donations that you'd like listed in the obituary

Special instructionsUse the area above to provide additional information or instructions to us.

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