Cleveland Cremation Pre-Arrangement Form

Name of Decedent
Prefix First Middle Name or Initial Last Suffix
Home Address
Street Address Address Line 2 City State ZIP Code
County
Is this address inside the city limits?
- Yes
- No
Social Security Number
Date of Birth
Month
Day
Year
City of Birth*
State of Birth*
Gender*
- Male
- Female
Date of Death
Month
Day
Year
Place of Death

Education Level
Elementary/Secondary
Race*
Ethnicity if Hispanic

(Cuban, Mexican, Puerto Rican, etc.)
Occupation (if retired, last job when you worked)*
Industry (if retired, when you worked)*

(medical/industrial/education/etc.)
Employer

Person in charge of your arrangements - Legal Next of Kin
Name
Prefix First Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Relation to Decendent*

(wife, husband, son, daughter, etc.)
Veterans Information
DD214 is Needed for Miltary Benifits/Honors
Branch of Military
Date of Entry
Month
Day
Year
Place of Entry
Date of Discharge
Month
Day
Year
Place of Discharge
I hereby certify that I am the nearest degree of relationship to the deceased and that I have the legal right or am charged to authorize this cremation and the disposal of the cremated remains. I understand that due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry (as well as any body prosthesis or dental bridgework), that are left with the decedent and are not removed prior to cremation will be destroyed or if not destroyed, will be disposed of by Cleveland Cremation Service. I further agree that I will indemnify and hold harmless the Cremator and Funeral Director, their officers and employees from any liability, costs, expenses or claims resulting from this authorization.
Authorization*
- Yes
- No
I give Cleveland Cremation authorization for cremation and I understand that this is my digital signature.
Once you have completed the Pre-Need form, please press the submit button and your information will be sent to our trusted staff. Once your information has been received, a staff member will contact you. Thank you for choosing Cleveland Cremation.

Pre-need

Step 1 of 4

Spousal Information

Father of Decedent's Information

Mother of Decedent's Information *(MAIDEN NAME)

Person in charge of your arrangements - Legal Next of Kin

Veterans Information