Pre-Plan Direct Burial

Arrangement Form

Please complete all questions below. If you have any questions, please do not hesitate to call us - 309-798-9798

Pre-Plan Direct Burial Arrangement Form (Pay Now)

Free Text

Informant Information

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

Relationship *

Free Text

Enter your free text here

First Name *

Middle Name *

Last Name *

Free Text

Deceased's Residence

Street Address *

City *

State *

Zip Code *

Country *

Free Text

Deceased's Personal Information

Social Security Number *

Gender *

Date of Birth *

Birth City *

Birth State *

Race *

Primary Ethnicity

Marital Status *

Free Text

Additional Information

Education Level *

Military Service *

Occupation *

Type of Business/Industry *

Free Text

Spouse Information

First Name

Last Name

Maiden Name

Free Text

Mother's Information

First Name *

Middle Name

Last Name *

Maiden Name *

Free Text

Father's Information

First Name *

Middle Name

Last Name *

How Did You Hear About Us? *

Comments/Special Instructions

The purchaser(s) hereby attest to the following: [1] I/We did ( ) did not ( ) authorize embalming of the above named deceased. [2] I/We were shown a Casket Price List and an Outer Burial Container Price List before the showing of caskets and outer burial containers. [3] I/We were given/offered for retention a General Price List upon the beginning of a discussion of funeral arrangements and/or selection of service and merchandise.