Membership Form

First Name:

Middle Name:

Last Name:

Address:

City:

State:

ZIP Code:

E-Mail:

Sex:

Male
Female

Phone:

Social Security Number:

Education (Years Completed):

Ancestry:

Race:

I am a U.S. Veteran:

Yes No

Occupation (Present or Before Retirement):

Employer:

Name of Spouse - First:

Name of Spouse - Last/Maiden Name:

Marital Status:

Married Never Married

Widowed Divorced

Name of Father - First:

Name of Father - Last Name:

Name of Mother - First:

Name of Mother - Maiden Name:

Next of Kin:

Name:
Phone:
Address: Relationship:

Please include any additional information you would like to be included in an obituary notice such as names of family members, organizations, activities, educational background and employment history:

By submitting this form, I hereby authorize and request the Heritage Services Group, in accordance with its rules and regulations, and any applicable laws or regulations, to take possession of, to cremate and to carry out the final disposition of my remains as instructed below.

Please check one of the following options:

• Release cremated remains to the following individual:
  Hand deliver cremated remains to the following individual:
  Ship cremated remains to the following individual:
  Hand deliver cremated remains to the following cemetery:
  Ship cremated remains to the following cemetery:
  Please have the Heritage Services Group arrange for the following scattering option:
  

Please fill out the following information:

Name of Individual or Cemetery:

Street Address:

City, State, Zip:

Cemetery Lot # or Niche # [If Applicable]

Scattering Option [If Applicable]

By submitting this form I indicate I have read and fully understand this document. Whoever is responsible for my final disposition must carry out my legally binding wishes as set forth in this document in which I have made known my full intentions.

Billing Information We accept Visa, Mastercard and Discover

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Card Number:

Expiration Date (mm/yy): 

Billing Address (if different than listed above):

Address:

City:

State:

Zip Code: