REQUEST FOR BURIAL

FOR FUNERAL DIRECTOR USE

This form is to be submitted only by the funeral director for the requested burial.

Name of Funeral Home *

Name of Funeral Director *

Phone Number of Funeral Director *

Email of Funeral Director *

Confirm Email of Funeral Director *

Will the funeral home be providing the vault? *

Yes

No

If yes, please list the vault company's name. Otherwise, please list N/A. *

Please list the vault company's phone number. Otherwise, please list N/A. *

Full Name (as it appears on the Death Certificate) of Deceased

Last *

First *

Middle *

Place of Death (as it appears on the Death Certificate)

City *

State *

Date of Birth *

Date of Death *

Was the deceased a member of the military? *

Yes

No

If yes, what branch?

Full Name (as it appears on the Driver's License) of Legal Representative of Deceased *

Relationship to deceased *

If another relative by blood relationship, please list.

Address of Legal Representative (Street Address) *

Address of Legal Representative (City, State, Zip) *

Phone number of legal representative *

Email of Legal Representative *

Confirm Email of Legal Representative *

Funeral Location (i.e. funeral home, place of worship, etc.) *

Funeral Date *

Funeral Time *

Requested Burial Date at Stafford *

Requested Burial Time at Stafford *

Availability for the requested burial date and time will be confirmed by the cemetery.

Burial Type *

Full Casket

Cremation

Casket/Urn Material *

Metal

Wood

Other

If other, please list the casket/urn material.

Casket/Urn Size *

Standard (27" casket)

Oversized (Larger than 27" casket)

Urn

If oversized or urn, please list the dimensions. Otherwise, please list N/A. *

Does the deceased own interment rights? *

Yes

No

If no, is the family looking for a specific location (i.e. to be close to family, etc.)?

Additional Comment(s):

Schedule

FOR FUNERAL DIRECTOR USE

FOR FAMILY (WITHOUT FUNERAL DIRECTOR) USE