Miller & Daughter Mortuary Immediate Need Form
Miller & Daughter Mortuary Immediate Need Form
DECEASED INFORMATION
Deceased Full Name
Deceased Full Name
*
First
Last
Date of Passing
Date of Passing
*
/
MM
/
DD
YYYY
Place of Passing
*
Date of Birth
Date of Birth
*
/
MM
/
DD
YYYY
LEGAL NEXT OF KIN INFORMATION
Name
Name
*
First
Last
Relationship to the Deceased
*
Phone Number
Phone Number
*
-
###
-
###
####
Email Address
*
PREARRANGEMENTS
Is there a prearrangement on file with us?
*
Is there a prearrangement on file with us?
Yes
No
If so, what name are the prearrangements under?
*
Add N/A if not applicable.
GENERAL DETAILS
Has the body been released for removal?
*
Has the body been released for removal?
Yes
No
Urgent Instructions or Other Requests