Cremation Consultants

362 Van Brunt Street

Brooklyn, NY11231

(718) 624-8969

(212) 929-9797

Vet:

 

SS#

 

Education:

 

 

 

Name:________________________________________________

Phone:_____________________________________

Place of Death:_________________________________________

Date: ______________________________________

Residence:_____________________________________________

County:_____________________________________

City:_________________________________________________

State:______________________________________

Zip:____________

Marital Status:_______________________________

(Never Married, Widowed, Divorced)

Husband / Wife (Maiden Name):_________________________________________

Date of Birth:______________________________

Age:__________

Place of Birth:______________________________

 

Occupation:_______________________________

Type:_______________________________

Fatherís Name:_______________________________________

Motherís First Name + Maiden Name: _______________________________________

Cemetery / Crematory:______________________________

Location:__________________________________

Date:___________________________

Person Authorizing:_________________________

Phone:__________________________

Address:_________________________________________________________________________

 

Relationship:_________________________________________________

 

 

 

Transcripts:__________________________________________________

 

 

 

Ashes:

 

_____________________________________________________

___________________________________________________

_____________________________________________________

___________________________________________________

_____________________________________________________

___________________________________________________

_____________________________________________________

Telephone #:_________________________________________