Cremation Consultants

362 Van Brunt Street

Brooklyn, NY 11231

(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:_______________________________
Father’s Name:_______________________________________
Mother’s First Name + Maiden Name: _______________________________________
Cemetery / Crematory:______________________________
Location:__________________________________	Date:___________________________
Person Authorizing:_________________________	Phone:__________________________
Address:_________________________________________________________________________
Relationship:_________________________________________________
Transcripts:__________________________________________________
Ashes:
_____________________________________________________	___________________________________________________
_____________________________________________________	___________________________________________________
_____________________________________________________	___________________________________________________
_____________________________________________________	Telephone #:_________________________________________