Cremation Society of Eastern - Central

The information provided on this form will help the cremation society complete the death certificate and other required documents. In addition, this information will assist the licensed director to better understand your initial wishes. Relaying required statistical information can be time consuming. Our desire is to help expedite the final arrangements and make the process a little more comfortable.

Please complete, as much as possible, the information on the form and select Submit Information at the end to email to the cremation society. You may also print out the form and bring it with you to the arrangementconference or fax it as well.

If you have any questions, please contact the cremation society at any time. Thanks again for placing your trust in the Cremation Society of Eastern Iowa and allowing us to serve you more efficiently.


Last Name:
First Name:
Middle Name:
Sex:
Race:
Date of Birth:	/ /
Place of Birth:	City State OR Country
Date of Death:	/ /
City of Death:
State of Death:
County of Death:
Location of Death:	If other, please indicate address:
Name of the Place of Death:
Social Security #:
Education
Usual Occupation: (most of life)
Kind of Business:
Company: (optional)
Doctor's Name
Doctor's Address
Marital Status:
Surviving Spouse:
If wife, provide maiden name:
Residence: (street Address)
City/Town:
Inside City Limits:
County:
State:
Zip Code:
Length of Residence in County:
Fathers Full Name:
Mothers Full Maiden Name:

Final disposition of the cremated body:

Name of Cemetery (if applicable):

City:
State:

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. The Cremation Society of Eastern Iowa provides a state of the art refrigeration facility for all unembalmed human remains.
The family preference regarding viewing/embalming is:


Was Decendent ever in the US Armed Forces?:
YES NO (if no, continue to next section)
Branch of Service:
Date Enlisted:	/ /
Date Discharged:	/ /
Honorable Discharge:	YES NO
Military Serial #:
Is copy of dischage papers available?
YES NO (if yes, please forward us a copy.)


Name of person in charge:
Relationship to deceased
Address:
City
State	Zip
Phone #:
Email:


Preferred Place of Service:
Religious Denomination (optional):
Is there Pre-Need Membership Agreement on decedent?:	YES NO


Note: Use box below to indicate any additional information that may be helpful at this time. Other details regarding services, merchandise, flowers, financing, etc., will be discussed and finalized at the arrangement conference. PLEASE CALL FOR AN APPOINTMENT. Thank you for completing our online arrangement form.