Pre-Planning - chapelofthehighlands

PRE-PLANNING / PRE-NEED / AT-NEED

When making pre-need arrangements your wishes and other personal information will be collected, kept privately on file and referred to at the time of death. In-turn this will avoid guesswork and help your surviving family in making correct decisions.

The following “Vital Statistics” are required by the state of California for the death certificate. Please fill out the below form in-full, carefully and accurately (detailing a loved-one or yourself). Double check the spellings and dates, then press submit at the bottom.

IMPORTANT: Please include your name, phone number and email address so we have a way to contact you.

Decedent Information:

Full Name of Decedent:

First

Middle

Last

Also Known As:

First

Middle

Last

Date of Birth

Single Line Text

Age

Sex

Social Security Number:

Birth Place

City

State or Foreign Country

If a Veteran:

Marital Status:

Date of Death

Hour of Death (please state AM or PM)

Highest Level of Education

Was Decedent Spanish / Hispanic / Latino?

Usual Occupation:

Kind of Business or Industry:

Years in Occupation:

Decedent’s Usual Residence:

Address

Address Line 1

Address Line 2

City

State

Zip Code

CA County of Residence:

Years in CA County:

Informant:

Person in charge of Arrangements: *

First

Middle

Last

Relationship to Decedent:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Alternate Phone:

Decedent’s Surviving Spouse & Parents:

Husband or Wife:

First

Middle

Last

Years Married:

If spouse deceased list date of death:

Father of Decedent:

First

Middle

Last

Birthplace of Father:

City

State

Country

Mother of Decedent:

First

Middle

Last

Birthplace of Mother:

City

State

Country

Final Disposition:

Type of Disposition:

Place of Disposition:

CA County of Disposition:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Office phone:

Cell Phone:

Alternate Phone

Place of Death:

CA County of Death:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Location Phone:

Cell Phone:

Alternate Phone:

Embalming Authorized

Kaiser # of decedent:

Decedent’s Attending Physician:

Name of regular Physician:

Office Phone:

Street Address:

Address Line 1

Address Line 2

City

State

Zip Code

Office Fax:

Type of Services:

Religion of Decedent:

Church Affiliation:

Name of Clergy:

Clergy Phone:

Place of Service - check all that are appropriate:

Church
Chapel of the Highlands
Cemetery or Burial Place
Other

Kindly fill in any additional information that would be of assistance to your funeral counselor

Survivors: Spouse, Sons, Daughters, Parents, Brothers, Sisters, Number of Grandchildren, etc.

Additional Family Info:

First, call our office to request your appointment before filling in a date and time:

Day:

Date:

Hour:

Keep the following in mind regarding your appointment to make “At-Need” or “Pre-Planning” arrangements at

Chapel of the Highlands

If you are unable to keep the above appointment, please call our office;
If an appointment has not been made, we will contact you and arrange for one;
If you wish, you may call us after 9:00 AM to arrange for an appointment;
It is important that you are on time for your appointment. We have set this time aside so we may better serve you.

Helpful Information and Advice:

Time of Funeral Services: Please do not set the time of funeral service without first confirming with our office.

Cemetery: It is advisable to complete Mortuary arrangements, including the casket selection, before making cemetery arrangements. The cemetery may have certain requirements that must be finalized at the Mortuary first.

Clothing – Ladies: May be purchased a time of arrangements or following items should be brought to the Mortuary at time of arrangement: underwear, stockings, slip, and dress or other suitable garments, and eyeglasses, if worn. If a recent picture is available, we suggest it be brought in also.

Clothing – Men: May be purchased a time of arrangements or following items should be brought to the Mortuary at time of arrangement: underwear, socks, suit, shirt, and tie, or other suitable garments, and eyeglasses, if worn. If a recent picture is available, we suggest it be brought in also.

Clergy: If you do not have your own clergyman, we will aid you in your selection.

Funeral Notices: Funeral Notices are inserted in the local papers by the Mortuary at the family’s request. We will assist you with the proper composition and format required.

Flowers: If flowers are desired we will consult with you as to the type or arrangement needed.

Insurance: When some forms of insurance are involved, special precautions must be taken to make certain that information you give us will compare favorably with the insurance record. We will aid the family or insurance agent in assembling the data necessary for prompt settlement of claim.

Veterans: Bring discharge or copy of discharge to Mortuary at time of making arrangements.

Shipment of Remains: If remains are to be forwarded to another city, we generally are able to promptly secure air or ground reservations. You will be required to inform us the name of the receiving funeral director.

A Word About Payment: Bring a checkbook with you for your appointment. We will guide you with various payment options.

Thank You: Please feel free to call us with any questions regarding the above instructions. We will do our best to help.

PRE-PLANNING / PRE-NEED / AT-NEED

Decedent Information:

Decedent’s Usual Residence:

Informant:

Decedent’s Surviving Spouse & Parents:

Final Disposition:

Place of Death:

Decedent’s Attending Physician:

Type of Services:

Kindly fill in any additional information that would be of assistance to your funeral counselor

First, call our office to request your appointment before filling in a date and time:

Keep the following in mind regarding your appointment to make “At-Need” or “Pre-Planning” arrangements at

Chapel of the Highlands

Helpful Information and Advice:

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