PRE-PLANNING / PRE-NEED / AT-NEED

Decedent Information:

Full Name of Decedent: *

First

Middle

Last

 

Also Known As:

First

Middle

Last

 

Date of Birth

Birth Month:

Birth Day:

Birth Year:

Age:

Sex:SexMaleFemaleNonbinaryUnknown/Undetermined

Social Security Number:

Birth Place

City:

State or Foreign Country:

If a Veteran:Veteran?YesNoUnknown

Branch of Service:Select Branch of Service (Airforce, Army, Navy, etc.)Air ForceArmyArmy Air CorpsArmy Air ForceCoast GuardMarine CorpsMerchant MarineNavySelected ServiceSpace ForceOther

* Attach military discharge (e.g. Form DD-214) below

Period Served:

Marital Status:Marital StatusMarriedWidowedDivorcedNever Married

Date of Death:

Time of Death (please state AM or PM):

Highest Level of Education:# of years or highest Degree01st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade with no diplomaGEDHigh School diplomaSome college but no degreeAssociate's degreeBachelor's degreeMaster's degreeDoctorate degreeProfessional degreeUnknownWithheld

Was Decedent Spanish / Hispanic / Latino?Spanish/Hispanic/Latino?NoYes

Hispanic Origin:Select Hispanic OriginCentral AmericanChicanoCubanMexicanMexican AmericanPuerto RicanSouth AmericanOther

Race:Up to 3 races may be listedAfrican AmericanAlaska NativeAleutAsian IndianBangladeshiBlackCambodianCaucasianChineseEskimoFijianFilipinoGuamanianHmongIndonesianJapaneseKoreanLaotianMalaysianMexicanMexican AmericanNative AmericanNative HawaiianPakistaniSamoanSri LankanTaiwaneseThaiTonganVietnameseWhiteOther AsianOther HispanicOther Pacific IslanderOtherUnknown

Race:Up to 3 races may be listedAfrican AmericanAlaska NativeAleutAsian IndianBangladeshiBlackCambodianCaucasianChineseEskimoFijianFilipinoGuamanianHmongIndonesianJapaneseKoreanLaotianMalaysianMexicanMexican AmericanNative AmericanNative HawaiianPakistaniSamoanSri LankanTaiwaneseThaiTonganVietnameseWhiteOther AsianOther HispanicOther Pacific IslanderOtherUnknown

Race:Up to 3 races may be listedAfrican AmericanAlaska NativeAleutAsian IndianBangladeshiBlackCambodianCaucasianChineseEskimoFijianFilipinoGuamanianHmongIndonesianJapaneseKoreanLaotianMalaysianMexicanMexican AmericanNative AmericanNative HawaiianPakistaniSamoanSri LankanTaiwaneseThaiTonganVietnameseWhiteOther AsianOther HispanicOther Pacific IslanderOtherUnknown

Usual Occupation:

Kind of Business or Industry:

Years in Occupation:

 

Decedent’s Usual Residence:

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

 

California County of Residence:Select CountyAlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYuba

Years in California County:

 

Informant:

Person in charge of Arrangements: *

First

Middle

Last

Relationship to Decedent: *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

 

Home Phone: *

Cell Phone: *

Alternate Phone:

Email *

Email

Confirm Email

 

 

Decedent’s Surviving Spouse & Parents:

Husband or Wife:

First

Middle

Last

Years Married:

Date and place of marriage (and other relative info):

If spouse is deceased, enter date of death:

Father of Decedent:

First

Middle

Last

 

Birthplace of Father:

City:

State:Father Birth StateAlaskaAlabamaAmerican SamoaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth Marianna IslandsNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasVirgin IslandsUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

Country:Father Birth CountryUnited StatesAfghanistanAlbaniaAlbertaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanAzoresBahamasBahrainBangladeshBarbadosBarbudaBelarusBelgiumBelizeBeninBermuda IslandsBhutanBoliviaBosniaBotswanaBouvet IslandBrazilBritish ColumbiaBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCaicos IslandsCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas Island (Indian Ocean)Cocos IslandsColombiaComorosCongo (Brazzaville)Congo RepublicCook IslandsCosta RicaCôte d' IvoireCroatiaCubaCyprusCzech RepublicDenmarkDistrict of ColumbiaDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFutunaGabonGambiaGaza StripGeorgia (Republic)GermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadinesGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard IslandHercegovinaHollandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJohnston AtollJordanKazakhstanKeeling IslandsKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaManitobaMariana Islands, NorthernMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMcDonald IslandMexicoMicronesia (Federated States)Midway IslandsMiquelonMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew BrunswickNew CaledoniaNew ZealandNewfoundlandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern IrelandNorthern Mariana IslandsNorthwest TerritoriesNorwayNova ScotiaNunavutOmanOntarioPakistanPalauPalestinePanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandPolandPortugalPrince Edward IslandPrincipePuerto RicoQatarQuebecRepublic of ChinaReunionRomaniaRussiaRwandaSaharaSaint HelenaSaint KittsSaint LuciaSaint PierreSaint VincentSamoa, AmericanSamoa, WesternSan MarinoSão ToméSaskatchewanSaudi ArabiaScotlandSenegalSeychellesSicilySierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth Sandwich IslandsSpainSpainish North AmericaSpratly IslandSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaTerres AustralesThailandTobagoTogoTokelauTongaTrinidadTunisiaTurkeyTurkmenistanTurks IslandTuvaluUgandaUK Misc IslandsUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnknownUpper VoltaUruguayUS Misc Caribbean IslandsUS Misc Pacific IslandsUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, USWake IslandWalesWallisWest Bank of the Jordan RiverWestern SaharaWestern SamoaYemenYugoslaviaYukon TerritoryZaireZambiaZimbabwe

Mother of Decedent:

First

Middle

Last

 

Birthplace of Mother:

City:

State:Mother Birth StateAlaskaAlabamaAmerican SamoaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth Marianna IslandsNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasVirgin IslandsUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

Country:Mother Birth CountryUnited StatesAfghanistanAlbaniaAlbertaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanAzoresBahamasBahrainBangladeshBarbadosBarbudaBelarusBelgiumBelizeBeninBermuda IslandsBhutanBoliviaBosniaBotswanaBouvet IslandBrazilBritish ColumbiaBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCaicos IslandsCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas Island (Indian Ocean)Cocos IslandsColombiaComorosCongo (Brazzaville)Congo RepublicCook IslandsCosta RicaCôte d' IvoireCroatiaCubaCyprusCzech RepublicDenmarkDistrict of ColumbiaDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFutunaGabonGambiaGaza StripGeorgia (Republic)GermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadinesGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard IslandHercegovinaHollandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJohnston AtollJordanKazakhstanKeeling IslandsKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaManitobaMariana Islands, NorthernMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMcDonald IslandMexicoMicronesia (Federated States)Midway IslandsMiquelonMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew BrunswickNew CaledoniaNew ZealandNewfoundlandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern IrelandNorthern Mariana IslandsNorthwest TerritoriesNorwayNova ScotiaNunavutOmanOntarioPakistanPalauPalestinePanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandPolandPortugalPrince Edward IslandPrincipePuerto RicoQatarQuebecRepublic of ChinaReunionRomaniaRussiaRwandaSaharaSaint HelenaSaint KittsSaint LuciaSaint PierreSaint VincentSamoa, AmericanSamoa, WesternSan MarinoSão ToméSaskatchewanSaudi ArabiaScotlandSenegalSeychellesSicilySierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth Sandwich IslandsSpainSpainish North AmericaSpratly IslandSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaTerres AustralesThailandTobagoTogoTokelauTongaTrinidadTunisiaTurkeyTurkmenistanTurks IslandTuvaluUgandaUK Misc IslandsUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnknownUpper VoltaUruguayUS Misc Caribbean IslandsUS Misc Pacific IslandsUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, USWake IslandWalesWallisWest Bank of the Jordan RiverWestern SaharaWestern SamoaYemenYugoslaviaYukon TerritoryZaireZambiaZimbabwe

 

Final Disposition:

Type of Disposition:Select Type of DispostionBurial/EntombmentCremationTransit outside of CaliforniaOther:

Cremation Checkboxes

• Kept at home
• Cemetery Burial
• Scatter at Sea
• Transit outside of California
• Other

Name & Address of Location Outside of California

If "Other":

Place of Disposition:

California County of Disposition (if applicable):Select CountyAlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYuba

Disposition Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Office Phone:

Cell Phone:

Alternate Phone:

 

Place of Death:

Place of Death:

CA County of Death:Select CountyAlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYuba

Place of Death Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Location Phone:

Cell Phone:

Alternate Phone:

 

Embalming Authorized:Embalming?YesNoUnsure

 

Kaiser # of decedent:

 

Decedent’s Attending Physician:

Name of regular Physician:

Office Phone:

Office Fax:

Physician Street Address:

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

 

 

Type of Services:

Religion of Decedent:

Church Affiliation:

Name of Clergy:

Clergy Phone:

Place of Service - check all that are appropriate:

• Chapel of the Highlands
• Church
• Cemetery or Burial Place
• Other
• No Services

 

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:

 

Upload supporting documents

Military discharge papers, obituary, good photo(s) for obituary/memorial book/service folders, cosmetics, etc.

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Allowed: gif, jpg, jpeg, png, doc, docx, txt, xls, xlsx, ppt, pdf, mp3, mp4, mpg, mpeg, mov, wav, wmv

Max limit: 512 MB

 

 

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

Arrangement Appointment:

Day of Week:

Date:

Time:

Name

Submit Form to CHAPEL OF THE HIGHLANDS

Keep the following in mind regarding your appointment for making “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.