IntroThank you for choosing Just Cremation Service, how may we serve you? How may we assist you?*Please let us know how we can help you.My loved one has just passed away.My loved one is about to pass away soon.I’m pre-planning for a loved one.I’m pre-planning for myself.Deceased InformationPlease provide us with the following information about the deceased. We will need this information in order to complete the death certificate and move forward with the cremation process. Who are you planning for?Please provide us with the following information about the person you are planning for. Who are you planning for?Please provide us with the following information about the the loved one you are planning for. Please provide details regarding the best way to contact you.Pre-Planning InformationPlease provide us with the following information about you. We will need this information in order to move forward with the Pre-Planning process. General Cremation InformationName* First Middle Last Maiden Last Name (if applicable)Sex*MaleFemaleDate of Birth*Date of PassingAge*Location of Your Loved One's Place of Passing (Please enter as much information as you know.)Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Confirm loved one's address The location where my loved one is currently is also their home address Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Place of Birth:* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State County Social Security NumberName as Listed on Social Security Card (If Known) First Middle Last Highest Education Attained*Race [ex, White, African/American, Asian]*Ancestry (Countries of Origin)*Hispanic Origin (Yes or No)*Military Service (Yes or No)*What was their job title?*In what type of business?*Marital Status*MarriedSingleDivorcedWidowedNever MarriedSpouse's Name at Birth (Only if Married) First Middle Last Father's Name* First Middle Last Mother's Name at Birth* First Middle Last Informant SectionInformant InformationThe informant is the person providing us with the information about the deceased. Informant's Name* First Middle Last (This is the person providing the information, whose name and address will also appear on the death certificate.)Relationship to Loved One*Informant's Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Informant's Phone*Who should we contact in regard to this pre-planning request?Name* First Last Phone*Email* Would you like to be contacted by a pre-planner for the purpose of pre-funding your funeral needs?* Yes No Important NotesPlease provide any important information that would be helpful in your planning. Example: Is your loved one being cared for at home or in hospice? What is the best contact number for the primary caregiver?Cremation Price Section Cremation Payment Options Your total for service is: $950 Payment OptionWould you like to pay now?*I would like to pay online.I would like to pay over the phone or in person. If you have any questions during this process, please call 616.288.9610 and one of our caring professionals will answer any questions you may have.
