“Open Casket” Funeral with Cremation to Follow $3,995.00 Package PriceWhen will you require service?(Required) Immediately- My loved one has passed Time-Sensitive Support: This option is for those receiving hospice care or who need prompt arrangements due to an imminent passing. I am pre-planning for the future Details of Individual Completing This FormYour First Name(Required) Your Last Name(Required) Relationship to the deceased(Required) Your Phone Number(Required)Your Email(Required) Name of Deceased(Required) Deceased First Name Deceased Middle Name Deceased Last Name Name for Preplan(Required) Preplan First Name Preplan Middle Name Preplan Last Name Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex Male Female Race Of Hispanic Origin Yes No Please specify: Date of Birth Birthplace (City and State) Social Security Number Marital Status Never Married Married Divorced Widowed Spouse's / Ex-Spouse Name First Last Maiden Name Employment InformationUsual Occupation (Prior to Retirement)Kind of Industry Father's InformationName First Last State of Birth (country if not USA) Mother's InformationName First Last Maiden Name State of Birth (country if not USA) EducationHighest Level Grade 1-8 Grade 9-12 No Diploma High School Graduate / GED Trade School / Certificate Some College, no degree Associates Degree Bachelors Degree Masters Degree Doctoral/Professional Degree Unknown Military ServiceVeteran Yes No Branch of Service Next of Kin InformationName of Next of Kin(Required) First Last Address of Next of Kin(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of Next of Kin(Required)Email of Next of Kin(Required) Relation to deceased Next of Kin/Authorizing Agent:(Required) I certify and represent that I have the right to make such authorization and am not aware of any living person who has a superior right or any next-of-kin or legal authority that have an objection to this cremation. Next of Kin / Authorizing Agent(Required) I agree to hold the cemetery harmless from any liability on account of said cremation. I understand that valuable material including jewelry and dental gold will likely be destroyed and/or not recoverable as a result of the cremation process. I give Boston Cremation authorization to capture a fingerprint and upload to Legacy Touch in the event I wish to purchase memorial keepsakes now or in the future.(Required) Yes No Deliver the cremated remains via insured, return receipt, first class mail to ($100.00 minimum fee applies). Yes Deliver Remains No I Will Pickup at Malden Care Center 287 Main St. Malden, MA 02148 Ship To (Name)(Required) First Last Ship To (Address)(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Release the cremated remains to the custody of AuthorizationYes - I give Boston Cremation authorization for cremation and I understand that this is my digital signatureAuthorization Name(Required) First Last Payment Type(Required) Credit Card Pay Offline Financing Package Total Payment InformationName As It Appears On Credit Card First Last Billing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card InformationCard Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.
