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The following information will be used for completion of all legal documents. Including, but not limited to, certified death certificates, cremation permits, social security notification and veteran claim forms.
Required fields are marked with an "
*
".
Informant and Next of Kin Information
*
Your Full Name
*
Your Relation to the Member
*
Street Address
*
City
*
State
Select State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip/Postal Code
*
Telephone
*
Email
Member Information
*
Member Legal Name
*
Gender
Male
Female
*
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
Birthplace
Social Security Number
Veteran?
Yes
No
Unknown
If Yes: Branch of Service
*
Marital Status
Married
Divorced
Married but Separated
Never Married
Widowed
Unknown
Surviving Spouse with Maiden Name
Member's Residence
Street Address
City
State
Select State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip/Postal Code
County of Residence
Member's Background
Member's Father's Name
Member's Mother's Name with Maiden Name
Highest Level of Education
Occupation
Industry
Of Hispanic Origin?
Yes
No
If Yes, What Origin (Mexican, Cuban, Puerto Rican, etc.)
Disposition
Cremation
Burial
Not Sure
Name/Location of Cemetery (If applicable)
I hereby authorize DuPage Cremations, Ltd. & Memorial Chapel to use the above information to complete all legal documents. I further state that this information is true and correct.
The following is an electronic signature:
*
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*
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