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Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form.

At-Need Arrangements Form

Step 1
Contact Information
Step 2
Decedent's Information
Step 3
Possible Service Arrangements
Step 4
Survivors' Information
Step 5
Additional Information

Contact Information

Full Name

Street

City

State/Province

ZIP/Postcode

Telephone #Best telephone number where you can be reached

Email Address

Anti-Spam Security Question

Decedent's Information

Personal Information

Full Name

Street

City

State/Province

ZIP/Postcode

Date of Birth

Place of BirthCity and State of Birth, or Country of Birth

Picture of Deceased.jpg or .png files only

Parents' Information

Father's Name

Mother's NameInclude Mother's Maiden Name

Father's Birthplace

Mother's Birthplace

Spouse's Name

Place of Marriage

Spouse's Maiden Name

Date of Marriage

Work/Education History

Highest Education Level

High SchoolGEDSome CollegeAssociates DegreeBachelors DegreeMasters DegreeDoctorateDid Not Graduate High School

Occupation

Company Name(s)

Business Field

Date of Retirement

Veteran's Information/Military Record

Did you serve in the military?

YesNo

Would you like Military Honors?

YesNo

Military Honors is a stirring tribute to a U.S. Veteran consisting of the appropriate branch of the Armed Forces performing a Folding & Presentation of a U.S. Flag, the Playing of Taps, and a Rifle Salute. A Form DD214 or other applicable discharge document is required.

Branch of Service

Date Entered Service

Date Discharged

Serial Number

Rank at Discharge

Discharge on file at

Wars Fought In

Do you have a copy of your discharge papers?

YesNo

Clubs, Organizations, Hobbies & Interests

Clubs, Organizations & AssociationsPlease include as many clubs, organizations, churches or associations, as well as positions held (if applicable) that the deceased was a member of.

Hobbies & InterestsPlease list any hobbies or interests that the deceased enjoyed doing, such as traveling, gardening, playing golf, cooking, etc.

Anti-Spam Security Question

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Street

City

State/Province

ZIP/Postcode

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Possible Service Arrangements

I Prefer

Service Information

Will there be a funeral service?

YesNo

Place of Service

Name of Location of ServiceFor services taking place outside of the funeral home, please list where you would like the service to take place (e.g. name of church, cemetery, or other location).

Religious DenominationIf you are in need of a priest, minister or other officiant for the service, we can make those arrangements for you. Please list the particular religious denomination you would prefer to lead the service.

Visitation Information

Will there be visiting hours?

YesNo

I Prefer

Place of Visitation

Name of Location of VisitationFor visiting hours taking place outside of the funeral home, please list where you would like the visiting hours to take place (e.g. name of church, or other location).

Cemetery Information

Name of Cemetery

Street

City

State/Province

ZIP/Postcode

Lot #(if applicable)

Section #(if applicable)

Grave #(if applicable)

Name of Original Cemetery Lot Owner(s)(if applicable)

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Street

City

State/Province

ZIP/Postcode

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Survivors' Information

Are either of the Parents of the Deceased still living?

YesNo

Is the Spouse of the Deceased still living?

YesNo

If Yes, which one?

Additional Family MembersPlease use the area above to list the names of siblings, children, grandchildren, great grandchildren, or anyone else you would like listed in an obituary or newspaper notice.

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Option 1Option 2

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Street

City

State/Province

ZIP/Postcode

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Additional Information

Will there be a collation or luncheon following the service?

YesNo

Name of Venue for Collation or Luncheon

Street

City

State/Province

ZIP/Postcode

Memorial requests or donations to charity

Additional instructions for us

Proud Members

Bellows Funeral Chapel • D. W. Bellows & Son, Funeral Directors • Roy Funeral Home

A Year of Daily Grief Support

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Immediate Need

We stand ready to assist you. If a death has occurred, please call us on the number below:

(401) 723-9792

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