PrePlanning

Who is this plan for?

First*

Full Middle*

Last*

What relation are you to this person?*

Phone*

Address (address, city, state, zip)*

Email*

Who should be listed as your Next-of-Kin, or contact person, on your behalf?

The fields below use NOK which is shorthand for Next of Kin.

NOK Name*

Relation To You*

NOK Phone*

NOK Address (address, city, state, zip)

NOK Email

What is your name and contact information?

Your Name*

Your Phone*

Your Email*

Your Address*

Services

In general, what type of services are you seeking?*

Cremation
Casket Burial

Will there be a funeral with viewing before the Cremation/Burial?*

Yes
No

Are you interested in prepaying for services?*

Please view our pricing page and the general price list if you are not familiar with our costs/services.

Yes
No

If not prepaying for services, we would hold this information on file along with any supporting documents. There is no membership fee involved for this. Prepayment generally isn’t for when there is hospice care, as it involves setting of a policy as an irrevocable trust (funeral/cremation providers are not allowed to hold money directly). Setting up the policy in this way protects the money in the case of the medicaid spend down situation, and the money is still available if using another funeral/cremation provider. We guarantee the current prices for our services when prepaying. If prepaying for services, after completing this form, we will contact you to coordinate completing a couple paperwork portions and then payment is made by check to the insurance company – United Heritage.

Death Certificate Information

Please fill in as best and accurately as possible, with all information relating to person named at the top for whom this is for.

Residence Address (no PO Box)*

Date of Birth

Place of Birth

Gender

Male
Female

Military Veteran

Yes
No

Please consider getting us a copy of the military discharge papers – the DD214, as this will be useful at the time of death

Marital Status

Never Married
Married
Divorced
Widowed

Name of Spouse (first middle, maiden)

Father (first, middle, last)

Mother (first, middle, maiden)

Middle names are optional for parents.

The social security number is needed if prepaying (for setting up the policy) and will be needed for filing the death certificate, however we will gather this sensitive piece of information later by other means.

Cemetery - This is optional for cremation.

Cemetery Name

Cemetery Location

Statistical Information - The following is information that does not show up on the death certificate, but is gathered by the government for statistical purposes.

Highest level of education completed

Ethnicity

Occupation

In what industry

Additional

How did you hear about us?

Notes for Crescent Tide

Please prove you are human by selecting the Star.

Following is a simple, one page form to be used to start the process for preplanning or prepaying. Please fill it out as completely as possible