For Immediate Support:
713-344-0764
For Immediate Support:
713-344-0764
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Vitals
DECEDENT'S VITAL INFORMATION
First Name
Middle Name
Last Name
Suffix
Please select an option
Jr.
Sr.
II
III
IV
V
Gender
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Female
Male
Unknown
Maiden Name
Date of Birth
Birthplace
Social Security
DECEDENT'S Residence
Street
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District of Columbia
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ZIP/Postcode
County
Is Residence Inside City Limits?
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Yes
No
Unknown
MARITAL STATUS
Marital Status
Please select an option
Never Married
Married
Widowed
Divorced
Unknown
Spouse's Full Name
Spouse's Maiden Name
OPTIONAL INFO
Is the decedent a military veteran?
Please select an option
No
Yes - US Army
Yes - US Navy
Yes - US Marine Corp
Yes - US Air Force
Yes - US Coast Guard
Race
Highest Education
Main Occupation
DECEDENT'S PARENTS
Father's Full Name
Mother's Full Name
Mother's Maiden Name
PERSON MAKING ARRANGEMENTS
Full Name
Relationship to the Person Above
Email Address
Cell Phone
Home Phone
Street
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
ZIP/Postcode
IF KNOWN
Date of Death
Place of Death
How Many Death Certificates Do You Need?
Would you like us to create an Online Tribute Page on our website?
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Yes
No
CREMATION DECISIONS
Is there a pacemaker present?
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Yes
No
After the cremation
Please select an option
The family will pick up from the Funeral Home
The Funeral Home will DELIVER (Local) Additional charges apply.
The Funeral Home will SHIP (Out of town) Additional charges apply.
After the cremation
URN SELECTION
After the cremation, in what type of container would you like your loved one's cremated remains returned? (choose one)
SERVICE / CEREMONY
Will there be a ceremony before or after the cremation?
Please select an option
PUBLIC Viewing/Funeral before the cremation
PRIVATE Viewing for immediate family before the cremation
Memorial Service after the cremation
No Service/Ceremony
FINAL Resting Place
Final Resting Place:
Please select an option
We already have a final resting place
Will be placed at Veteran Cemetery
Would like info about cemetery/niches
We plan to scatter the remains
Will keep the urn at home
Submit Information
Visit
www.prepaidfunerals.texas.gov
for information relating to the purchase of pre-need funeral contracts including descriptions of the trust and insurance funding options available under state law.
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