Arrangements – Funeral Arrangements Portal

Funeral Arrangements Questionnaire

Please fill out the questionnaire accurately and completely You may return to this page as many times as you like to resume filling out the questions. Your questions will save as you advance to each subsequent section, and you can hit Save Draft near the bottom of the page to save a partially-complete section. Please ensure all fields are filled out prior to finalizing.

Questionnaire Submitted You or a person with access to this account has already submitted a questionnaire to Claybar. This information will be available during your arrangement conference. Your director will be able to correct or edited as needed at that time. If you have any questions, please call 409-886-4445.

Funeral Arrangements

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The information requested below will be used to complete any arrangements you desire and is required to file various legal documents such as the Certificate of Death. Please feel free to call us with any questions or if we can assist you in completing this form. (409) 886-4445

Personal History - Legal Documentation

This information is pertaining to the individual for whom these arrangements are being planned.

Preferred Name for Obituary or Publication *

First Name *

Middle Name

Last Name *

Maiden Name, If Applicable

Birthdate *

Date of Death *

Person Arrangements Are For's Street Address

Address Line 2

City

State (ABBR)

Zipcode

Birth City / Township

Birth State

Age

Social Security Number

Father's First Name (if known)

Father's Middle Name (if known)

Father's Last Name (if known)

Mother's First Name (if known)

Mother's Middle Name (if known)

Mother's Last Name (if known)

Mother's Maiden Name (or list as unknown)

Occupation (or list as unknown)

Industry/Type of Business (or list as unknown)

Military Service

Yes

Branch of Service (if applicable)

If Married, Name of Spouse

Spouse Middle

Spouse Last

Gender *

Male

Female

Funeral Arrangements Questionnaire

As you begin...

Personal History - Legal Documentation

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