Vitals Form - CremateSimply® - Northeastern Wisconsin

Vital Stats

"*" indicates required fields

1Review Information

2Decedent Info

3Life Details

4Military

5Will

6Final Questions

We have collected some of the information needed to process the Death Certificate, and put together the documents needed for the authorization of cremation. Take a look down below to make sure what you’ve already filled out is correct.

Service Area*

Funeral Home*

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Funeral Home Name

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Business Email

Decedent Name*

First Middle Last

How are you related/connected to the decedent?*

Other

Date of Birth

MM slash DD slash YYYY

Date of Death

MM slash DD slash YYYY

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How old was ?

Location of Death

Place of Death Address

Location Name/Street Address Address Line 2 City State ZIP Code

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Primary Residence

Yes

Hidden

At Place of Death

Yes

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Deceased Location

Location Name/Street Address Address Line 2 City State ZIP Code

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Your Name

First Middle Last

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Your Address

Location Name/Street Address Address Line 2 City State ZIP Code

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Your Email

Enter Email Confirm Email

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Phone

Hidden

Confirm Phone

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Method of Contact

Phone

Hidden

Delivery Method

Please deliver in person ($100 delivery charge)

Please send by USPS ($125 shipping charge)

I’d like to pick up the ashes from your location

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Are you receiving the remains?

Yes

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Recipient Name

First Last

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Recipient Email

Enter Email Confirm Email

Hidden

Recipient Phone

Hidden

Confirm Recipient Phone

Hidden

Recipient Address

Location Name/Street Address Address Line 2 City State ZIP Code

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Professional Services

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Facilities Selected

Hidden

Transportation

Hidden

Taxable Merchandise

Hidden

Special Charges

Hidden

Cash Advanced

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Services, Facilities, and Transportation Total

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Total of All Sections

Hidden

Tax

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Balance Due

Hidden

Final Viewing Options

None

Simple viewing of your loved one for less than 20 people (up to 30 minutes)

Package offering of pre-cremation viewing followed by presence for the cremation

Was 's full legal name " "?

Yes

What was 's legal name?

First Middle Last

Did use a name different than their full legal name?

Yes

Please list the other names used

First Name

Middle Name

Last Name

What was 's gender?*

Male

Female

What was 's race?

Specify Race

Did have any Hispanic heritage?

Yes

Ethnicity

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Where was living at the time of death?

Location Name/Street Address Address Line 2 City State ZIP Code

's Last Name at Birth

Where was born?*

City State / Province / Region Country

's Mother's Name

First Middle (optional) Last Name at Birth (Maiden Name)

's Father's Name

First Middle (optional) Last Name at Birth

What level of education did have?*

What is 's marital status?*

Just to confirm, you were married to at the time of death, correct?

Yes

What is 's spouse's name?

First Middle Last

What was 's spouse's last name at birth (if different)

What is 's partner's name?

First Middle Last

Does have any living children?

Yes

Just to confirm: didn't have any children, and does not have a living spouse?

That’s correct

No, that’s not correct

How many living children does have?

Besides you, how many other children does have?

Just to confirm: you're 's only child?

That’s correct

No, that’s not correct

Since has other living children, Colorado state law requires that a majority of those children sign the death certificate and cremation authorization. Can we gather some information about those individuals?

Yes

No, let’s do that later

Yes

No, let’s do that later

Please list 's children

First

Middle

Last

Email Address

Please list 's children

First

Middle

Last

Email Address

Does have any living siblings?

Yes

Please list 's siblings

First

Middle

Last

Email Address

Thanks. We’ll need to have the decedent’s spouse sign the death certificate and cremation authorization, but we can proceed for now.

Thanks. We’ll need to have the decedent’s partner sign the death certificate and cremation authorization, but we can proceed for now.

What was 's occupation?*

What type of industry did work in?*

What is 's Social Security Number?

Was a veteran?

Yes

The information below is not required for a Death Certificate, but can be helpful for applying for VA benefits later on.

Branch of Service

Serial Number

Rank

Date of Induction

Place of Induction

Date of Separation

Place of Separation

If we are scheduling an interment at a national cemetery, or scheduling military honors, please upload the DD214 retirement document here

Accepted file types: pdf, jpg, png, gif, tiff, Max. file size: 10 MB.

Did have a will?*

Yes

I’m not sure

If you have a copy of the will, you may upload it here

Accepted file types: pdf, Max. file size: 10 MB.

Are you the person named as the personal representative of the will?

Yes

I’m not sure

Do you know the name of the person named as the personal representative of the will?

Yes

If not, don’t worry, we can come back to this later.

Who is the personal representative of 's will?

First Middle Last

We’ll need the personal representative to sign the cremation authorization.

If you’re not sure, we can keep the process moving for now and come back to this later.

Okay, we’ll need to clarify a few details about before we can arrange pickup, but we’re almost finished.

Do you have any special requests, notes or important information that you would like to share with us at this time?

Yes

Special requests, notes, or other information

Did have any implanted mechanical or radioactive devices (like a pacemaker)?

Yes

Please describe the implanted device to best of your ability

Would you like to create an obituary to place on our website?

Yes

Obituary Text

Do you have any questions that we can help answer at this time?

Yes

Questions