Smith-Lund-Mills Funeral Chapel & Crematorium

Immediate Need Form

 

Please be as complete and accurate as possible. This information will be used on legal documents and corrections are difficult to make.

This information is required for information on the Oregon Certificate of Death. Required fields are marked with an "*". If you do not have all of the information we will collect it from you later. If you have any questions please call us at 541-942-0185.

A note about privacy:
Your privacy is very important to us. We will not ask you for personal information unless we truly need it. To help further explain our commitment to your privacy we have included a link to our Privacy Policy.

Decedent's Information

* Legal Name:
* Sex:
*SSN:
* Birth Date:
* Birthplace:
* State or Country of Birth:

Death Information

* Date of Death:
Time of Death:
Age - Last Birthday:
County of Death:
Place of Death:
Was the Decedent on Hospice?
Facility Name:
City or Town:
State:
Zip Code:

Decedent's Background

Decedent's Education:
Was Decedent of Hispanic Origin?
If other, please specify:
Race:
If other, please specify:
Armed Forces:
If you would like us to apply for veterans benefits we will need a photo copy of the discharge papers often know as a (DD214).
Branch of Service:
Name any other Branch:
Location of Combat, if any: World War II
Korea
Vietnam
Lebanon
Grenada
Panama
Persian Gulf
Somalia
Bosnia
Yugoslavia
Kosovo
Afghanistan
lraq
Global War on Terrorism
Name any other location in this space
Where in World War II? European-African- Middle Eastern Campaign 12/7/1941 to 11/8/1945
Asiatic-Pacific Campaign 12/7/1941 to 3/2/1946
American Campaign 12/7/1941-3/2/1946
Merchant Marines, in Oceangoing Service from 12/7/1941 to 8/15/1946
Name any other locations:
* Residence Address:
* City or Town:
County:
* State or Foreign Country:
* Zip Code:
Inside City Limits?
Usual Occupation (Do not use Retired):
Business/Industry (Do not use company name):

Spousal & Parental Information

* Marital Status:
Surviving Spouse's or Domestic Partner's Name Before First Marriage:
Father's Name:
Mother's Name Before First Marriage:

Informant Information

* Informant's Name:
* Enter Informant Name Again:
* Relationship to Decedent:
* Street Address:
* City or Town:
* State:
* Zip Code:
* Phone Number:
* Email Address:

Disposition Information

Method of Disposition:
Place of Disposition:
Location:
Name of Funeral Facitlity:
Address of Funeral Facitlity:
Name of Doctor:
Contact Number of Doctor:

Additional Information

Do you have any questions for us?
Is there any other additional information you would like to request?

Preparation and Viewing

Important Note: Viewing of the body is a choice of the family. In many cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming.

Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.

The Family Preference Regarding Viewing/Embalming Is:
I Authorize Smith Lund Mills Funeral Chapel & Crematorium To Embalm:
Name of Authorizing Person:
Relationship To Deceased:

Funeral/Memorial Service Information

Preferred Place of Service:
Religious Denomination:
Is there Immediate Need Funeral Insurance on decedent?: Yes No
If Yes, Specify Insurance Type:
(i.e., Forethought, Purple Cross, trust, etc.)
Policy Number:




Immediate Need
Testimonials
Very nice people, very professional, very efficient & organized."
Jean M.

 

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