Funeral Agents

Pre-Need Form
Vital Statistics

Facing the loss of a loved one is perhaps the most difficult event we all face. You can make it easier by recording your own personal information and preferences. We will keep this information on file and you may add to it, update it, or come in and complete your pre-planning at your convenience.

Please fill out all information completely. It is used for the preparation of the death certificate and held in strict confidence. Please make sure all this information is correct and filled in completely.

General Information

First Name
Middle Name
Last Name
Also Known As
Social Security Number
Gender/Sex	MaleFemale
Date of Birth
Birthplace, (City and State)
Residence (State)
Residence (County)
City/Town
Address
Apartment#
Zip Code
Veteran	YesNoUnknown
Branch of Service	NoneAir ForceArmyCoast GuardMarineNavyNational Guard
Name of War
Dates of Service
Marital Status	Single/Never MarriedMarriedMarried but SeparatedDivorcedWidowedCivil Union PartnerCivil Union DissolvedCivil Union (Deceased)Domestic PartnerDomestic Partner TerminatedDomestic Partner (Deceased)Unknown
Spouse First Name
Spouse Middle Name
Spouse Last or Maiden Name
Father First Name
Father Middle Name
Father Last Name
Mother First Name
Mother Middle Name
Mother Maiden Name
Next of Kin or Person Responsible for Final Affairs
NOK Relationship	HusbandWifeSonDaughterFatherMotherSisterBrotherOther
If other, Please Specify
NOK Address
NOK City/Town
NOK State
NOK Zip
NOK Phone Number (Including Area Code)
NOK Email
Please indicate if Pre Pay?	YesNoNot Sure
Education	K123456789101112College 1 yrCollege 2 yrCollege 3 yrCollege 4 yrCollege 5+ yr
Degrees/Certificates
Race
If Hispanic Specify Origin
Usual Occupation
Type of Business
Name and Address of Last Employer
Number of Death certificates requested (see below) *
Verification:

USE THE CHECK LIST BELOW TO ESTIMATE THE NUMBER OF
CERTIFIED COPIES OF DEATH CERTIFICATES THAT WILL BE NEEDED

Listed below are a number of items that will require a certified copy of the death certificate.  Although there may be certain exceptions depending on the institution, the majority of the time the certified copy will be required.

When ordering certified copies of the death certificate, there is a $5.00 NJ State Permit and Filing fee in addition to the State of New Jersey charges of $25.00 for first copy and $2.00 for each copy thereafter.  To help order the proper amount, you may want to contact your financial advisor or attorney.

Remember when handling any of the items below always ask for the certified copy back so that you may reuse it for other situations.

_____ Transfer of real property (houses, lots, etc.) for each county of ownership

_____ Settling insurance claims (each company will require one)

_____ Obtaining union benefits (2 or 3 are commonly required)

_____ Transfer of titles on automobile, trailer, boat, camper, etc. for each county of    registration

_____ Transfer of stocks or bonds (1 for each certificate unless held at the brokerage company in “street name” but to be sure, check with your broker)

_____ Transfer of bank accounts (checking, savings, trust, etc.) 1 for each establishment

_____ Entry into bank safe deposit box

_____ Filing for Federal or State income tax refunds

_____ Social Security Benefits for surviving spouse or dependent children

_____ Veteran’s Administration benefits (the state provides 1 copy at no charge)

_____ Insured loans and insured credit cards

_____ Credit Union accounts

_____ To qualify for bereavement time with some employers

_____ Personal requests from children or other family members

_____ Mortgage insurance