Cremation Death Certificate

Email, Fax or Print & Mail Registration

Or Mail To : 5438 Flora Avenue Holiday, FL 34690-6501-USA

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The following information is required to comply with State Vital Statistic Requirements and applies to 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
County
Social Security
Issuing Country of SS#
Present Age
Gender
Date Of Birth
City or Country of Birth
State of Birth or if out of US, Country
Was member ever in the US Armed Forces?
Branch of Service
Title of Longest Occupation
In What Industry was the Occupation
Hispanic origin
If Yes, Specify
Race
Education
Father's full Name
Mother's full Name (maiden)
Type of Arrangement being made:

Name of Recepient of Cremated Remains
Phone Number of Recipient
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
Printed Name
Your Legal Relation
Signature
Date
Drivers license # or State ID :
State of issue
Date of issue

Type comments, obituary or additional information here:

You may request a blank printed version 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

Information for Veterans using a National Cemetery or

Placement of a Memorial Marker

Some options may not be available

Name to appear on marker as:
Religious Emblem or Request "None"	Marker Application
Optional Inscription or No
Is Surviving Spuse A Veteran?
Any Prior Burials in a National Cemetery?
Inground Burial or Above Ground Niche?
Name & State of "Active" National Cemetery?

Updated for Fall of 2007

American Heritage Cremation Society

5438 Flora Avenue Holiday, FL 34690-6501 USA

By Appointment