Print This PageTell A FriendAdd To Favorites
 


Informant Details

Please fill out your contact information (yours, not the deceased)
Name
Relationship to Deceased
Address:
City
State
Zip
Phone Number:
Email Address:

Descendent Details

First Name:
Middle Name:
Last Name:
Gender:
Birth Date: / /
Birth Place: (city/state)
Death Date: / /
Death Place (city/state)
Location of Death:
If other, please indicate address:



 
Place of Death:
Time of Death:
Social Security #:
Education
Occupation:
Company: (optional)
Marital Status:
Surviving Spouse:
If wife, provide
maiden name:
Residence:
(Street Address)
City:
County:
State:
Zip Code:
Length of Residence
Fathers Full Name
Mothers Full Maiden Name

Disposition Details

Disposition will be:
Disposition of ashes: (Cremation only)
Cemetery Name
City:
State:

Embalming/Viewing Details

The family preference regarding viewing/embalming is:
I authorize Lohman Inc. to embalm:
Name of authorizing person:
Relationship to deceased

Military Information

Was the deceased ever in the United States Military?:
Yes No

Funeral or Memorial Service Details

Preferred Service Location:
Religious Denomination (optional):
Is there Pre-Need Funeral Insurance? Yes No

Additional Instructions

Please use the field below to provide any additional details that may be useful at this time.