Cremation Death Certificate

Print & Mail or Fax Registration

Each registration requires $25 payable to AHCS

Mail to :5438 Flora Avenue Holiday, FL 34690-6501

Press your tab key to start entering information.

The following information is required to comply with State Vital Statistic Requirements

& applies to the person whom the arrangement is for.

First Name
Middle
Last Name
Legal Marital Status
If Married Spouses First name:
& Spouses Maiden Name:
Member's Phone
Residence
City
Inside City Limits?
Spell State
Zip Code
Country
Social Security
Issuing Country of SS#
Present Age
Gender
Date Of Birth
City or County of Birth
State of Birth or if out of US, Country
Was member ever in the armed forces?
Branch of Service
Longest occupation
What Industry
Hispanic origin
If Yes, Specify
Race
Education
Father's full Name
Mother's full Name (maiden)
Return Cremated Remains to
Address for Cremains
Next of Kin ( Not Spouse )
Next of Kin Address
Phone

By my signature and or mailing of this registration I acknowledge that the above information will be relied on for the death certificate of the registered name above. I affirm that I have proof read for accuracy of dates, numbers and spelling.

Email
Email - confirm
Signature
Date
Drivers license # or State ID :
State of issue
Date of issue

You may request printed copies of this form to be sent by mail by calling 1-800-756-2311

Press "Ctrl & P" on your keyboard to print this form.

Fax -1-866-263-6548

Processing for payment will be mailed once payment has been received.

Membership cards will be issued upon completion.

Comments or write your obituary here:

Updated for Winter of 2005 - 2006

American Heritage Cremation Society

5438 Flora Avenue Holiday, FL 34690-6501

By Appointment