Funeral Home Intake Form Funeral Home Information CompanyThis field is for validation purposes and should be left unchanged.Date of SubmissionDate(Required) Funeral Home(Required)Funeral Director(Required)Funeral Director Email(Required) Information for the DeceasedFull Name(Required)Date of Birth(Required) Date of Death(Required) Age(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Baptized(Required) Yes No Registered Parishioner(Required) Yes No Envelope NumberPlease provide for updating our records.Information for Next of Kin & Funeral PlannerNext of Kin Name(Required)Relationship to Deceased(Required)Next of Kin Phone(Required)Next of Kin Email(Required) Is the Next of Kin the contact for the Funeral Mass planning?(Required) Yes No If no, Name of Contact for the Church(Required)Contact's Phone(Required)Contact's Email(Required) Funeral Request DetailsIs this a Funeral Home Only service? Yes, the family does not want a Mass at the church. No, the family wants a Mass at the church. If Funeral Home Only service, what date and time is the family requesting? (This is subject to availability)(Required)DateTime Add RemoveGraveside service after Funeral Home Only service?(Required) Yes No Which Cemetery and at what time is the family requesting a Graveside service after the Funeral Home Only service? (subject to availability)(Required)DateTime Add RemoveRemains for Funeral Home Only service.(Required) Casket Urn Language of Services at Funeral Home Only service?(Required) English Spanish Bilingual If the family wants a Mass at church, what date and time is the family requesting? (This is subject to availability)(Required)DateTime Add RemoveWake service at funeral home the evening prior to Mass at church?(Required) Yes No If yes, what time?Graveside service after Funeral Mass?(Required) Yes No If yes, name of CemeteryMusic for the Funeral Mass?(Required) Yes, Mass with music No, Mass without music Remains for Mass at church.(Required) Casket Urn Language of Services at Mass in church?(Required) English Spanish Bilingual
