At-Need Form

AT NEED INFORMATION

PLEASE FILL OUT THIS FORM FOR DEATH CERTIFICATE INFORMATON AND OBITUARY.

Decedent's Full Legal Name(Required)

First Middle Last Suffix

Decedent's Alternative (Prefered) Name

If there is one?

Decedent's Age(Required)

Decedent's Date of Birth(Required)

Decedent's Birth Place(Required)

Decedent's Gender(Required)

Male

Female

Decedent's Race(Required)

Required By Ohio Vital Stat.

Decedent's Legal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Decedent's County of Residence(Required)

Decedent's Address – City Limits?(Required)

Yes

Decedent's Social Security Number (If Known)

Decedent's Date of Death(Required)

Decedent's Place of Death(Required)

Choice of Funeral Home Wanted?(Required)

We have 3 locations. Logan – Nelsonville – Murray City

Choice of Funeral Director Wanted?(Required)

We have 3 Directors

Decedent a Veteran?(Required)

Yes

Decedent a Veteran Branch (If Applicable)

We will need a copy of their DD214 discharge form, or you can fill out a request to order a copy.

Decedent a Veteran Entry and Exit (If Applicable/Known)

Decedent Marital Status(Required)

Decedent's Spouse Address (If Applicable -If Same as Decedent, Write Same)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Decedent's Occupation and Business Type(Required)

(Can Not be Retired – Can be Disabled)

Decedent's Father's Name(Required)

First Middle Last Suffix

Decedent's Mother's Name(Required)

First Middle Last Suffix

Decedent's Mother's Maiden Name(Required)

Informant's Highest Education Level(Required)

Informant's Legal Name (Next of Kin)(Required)

First Middle Last Suffix

(Person filling this form out or legal next of kin)

Informant's Phone Number(Required)

Informant's Email

Informant's Legal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Informant's County of Residence(Required)

Informant's Legal Address – City Limits?(Required)

Yes

(Person filling this form out or legal next of kin)

ANY QUESTIONS OR CONCERNS FOR THE DIRECTOR?

OBITUARY INFORMAION – Parents Surviving Names?

OBITUARY INFORMAION – Spouse Surviving Names?

OBITUARY INFORMAION – Children Surviving Names?