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At Need Arrangements Vital Statistics Form

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At Need Arrangements

Cremation Authorization Form

General Price List

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

Decendent of Hispanic Origin?

Not Spanish/Hispanic/Chicano

Mexican/Mexican American/Chicano

Puerto Rican

Cuban

Other (specify in Comments section below)

CommentsComplete the Comments box above only if you need to supply specifics on Origin or Race

Decedent's Race

White

Black or African American

Asian Indian

Chinese

Filipino

Japanese

Korean

Native Hawaiian

American Indian or Alaska Native (specify in Comments section to the left)

Vietnamese

Guamanian

Chamorro

Other Asian (specify in Comments section to the left)

Pacific Islander (specify in Comments section to the left)

Other (specify in Comments section to the left)

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 Less

9 12 no diploma

High School Graduate or GED completed

Some college credit but no degree

Associate degree (AA, AS etc.)

Bachelors degree (BA, AB, BS etc.)

Masters degree (MA, MEd, MEng, MM, MS etc.)

Doctorate (PhD, EdD, DMA, DM etc.) or Professional degree (MD, JD etc.)

Unknown

If unable to establish the highest level of education attained at this time, please be sure to have this information available at the Arrangement Conference

Veteran information

Was the decendent ever in the US Armed Forces?

YesNo

If no, continue to Employment History

Branch of service

Honorable discharge

YesNo

Copy of discharge papers is available

YesNo

Discharge papers (Form DD214) are required for applying for Veterans benefits, including burial/inurnment in a Veterans Cemetery. Please make every effort to bring a copy of the decedent's discharge papers to the Arrangement Conference.

Employment History

Usual occupation (most of life)

Type of business/industry

Marital status

Surviving Spouse

If wife, enter maiden name

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/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

Yes

Will 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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