On-line Immediate Need Form

Thanks for taking the time to fill out our Immediate Need Form. By completing the following information at your own convenience, you should find it easier to provide correct information and have some time to think about the type of services you desire.

The information provided on this form will help Spear Miller Funeral Home complete the death certificate and other required documents. In addition, this information will assist the funeral director to better understand your initial wishes. Relaying required statistical information can be time consuming. Our desire is to help expedite the final arrangement conference at the funeral home and make the process a little more comfortable.

Please complete (as much as possible) the information on the form and select Submit Information at the end to send the information to us. You may also print out the form and bring it with you to the arrangement conference or fax.

If you’d prefer, a printer-friendly version of this form is also available for you to download and fill out manually. CLICK HERE for further instructions and the download link, if interested.

If you have any questions whatsoever, please contact Spear Miller Funeral Home at: 203-259-0824.

Form name - click to set options

Deceased Vital Statistics for Death Certificate

Name:*First, Middle, Last

Sex:

Age:

Date of Birth:

Place of Birth:

Street

City

State/Province

ZIP/Postcode

Date of Death:

Place of Death:

Street

City

State/Province

ZIP/Postcode

Location of Death:

If other, please indicate address

Name of the Place of Death:

Education:

Usual Occupation (most of life):

Kind of Business:

Company:

Marital Status:

Full Name of Surviving Spouse:

If Wife, Provide Maiden Name:

Residence:

Street

City

State/Province

ZIP/Postcode

Length of Residence In County:

Father’s Full Name:

Mother’s Full Maiden Name:

Type of Disposition

Disposition Will Be:

If Cremation, Indicate Preference For Disposition of Ashes?:

Name of Cemetery (if applicable):

Cemetery Address:

City

State

Preparation and Viewing

Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming.

Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.

The Family Preference Regarding Viewing/Embalming Is:

I Authorize Spear Miller Funeral Home To Embalm:

Name of Authorizing Person:

Relationship To Deceased:

Veteran Information

Was Decedent Ever In the US Armed Forces?:

Yes

No(if no, continue to next section)

Branch of Service:

Date Enlisted:

Date Discharged:

Honorable Discharge:

YesNo

Military Serial Number:

Is A Copy of Discharge Papers Available?

Yes

No(if yes, please bring for us to copy)

Informant/Person In Charge Information

Name:*First, Last

Relationship To Deceased:

Email Address:*

Address:

Street

City

State/Province

ZIP/Postcode

Telephone Number:

Funeral/Memorial Service Information

Preferred Place of Service:

Religious Denomination:

Is there Immediate Need Funeral Insurance on decedent?:

YesNo

If Yes, Specify Insurance Type: (i.e., Forethought, Purple Cross, trust, etc.)

Other Information & Instructions

Please list any other instruction or information you would like us to have:

Immediate Need Form – Printer-friendly Version

You can download the printer-friendly version of the Immediate Need Form to your local computer from the link below. Once downloaded, open the PDF *, and enter your information on the form, then print it out on your printer. You may then either mail or fax it to us at the address or fax number below, or bring it with you when you visit.

CLICK HERE to download the form – choose to, ‘Save to Disk,’ in the dialog box that appears (download times will vary depending upon connection.)

Spear Miller Funeral Home
| 39 South Benson Road
| Fairfield, CT 06824
| Tel: 1-203-259-0824
| Fax: 1-203-254-8522

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