Online Burial Arrangement Form This information is sacred to us. We won't ever sell or abuse it. Should you not know the answer to a question, simply type in "will call" or if cannot find the answer, type "unknown".All of this data MUST be answered on the legal document and cannot be left blank.Name* First Last Email* Phone*I am Planning For:*Choose OneMy ParentMy SpouseMy SiblingMy ChildMy FriendOtherYour Relationship to the person you are planning for*Spouse, Child, Sibling, Friend, Companion, Etc.Your Address* Street Address City State Zip Full Legal Name (including maiden) of person to be buried:* First Middle Last Maiden Decedent's Address* City State Zip Inside City Limits?* Yes No Not Sure Phone Number:*Place of BirthCity, State or CountryDate of Birth* MM slash DD slash YYYY Sex:* Male Female Marital Status* Married Divorced Widowed Never Married Race*White, Black, Asian, Native American, OtherOf Hispanic Descent:*Choose OneNoMexicanPuerto RicanSpaniardOtherSocial Security Number*XXX-XX-XXXXFather's Name*FIRST, MIDDLE (not required), LASTMother's Name:*FIRST, MIDDLE (not required), LASTMother's Maiden Name :*Highest Level of Education Completed*Choose One8th Grade or Less9th thru 12th (No Diploma)High School Graduate or GEDSome College but No DegreeAssociates DegreeBachelor's DegreeMaster's DegreeDoctorate (Phd, EdD) or Professional Degree (MD, DDS, JD)Occupation:*The type of work one primarily did within a particular industry. Example: Homemaker, Teacher, Nurse, Loan Officer, Electrician, etc.Kind of Business or Industry*The type of industry one was involved in primarily throughout their life. Example: Domestic (Household), Education, Healthcare, Construction, Banking, etc.Ever Served in U.S. Military:*Choose OneYesNoUnknownBranch of Service:Ever Served as a TX Peace Officer:* Yes No Informant's Legal Name:*FIRST, MIDDLE (not required), LASTInformant's Email Address/Fax Number:Informant's Phone Number:Informant's Address: City State Zip Informant's Relation to Decedent:*How Did You Hear About Us* Google Yahoo/Bing Other Internet Facebook Newspaper Hospital Hospice Funeral Home Other Referral Survivors:Preceded in Death by:Additional Information:Funeral Service to be:* Public Private Permission to Embalm Body (required for viewing):* Yes - for Viewing (Package 1 ONLY) No - for No Viewing Select a Funeral Plan:* Package 1 Package 2 Package 3 Select a Casket:* Minimum Included Upgrade to Good Upgrade to Better Upgrade to Best Clothing & Underclothing:* Yes - We will Bring No - None Provided, No Viewing Hair/Cosmetic Instructions (for PLAN #1 ONLY):Name of Minister & Contact Information:Any other details the funeral home needs to know about the service? (Music, Pallbearers, Memorial Contributions, etc.)Tell us your plan for Casket Flowers:Submit the Obituary. Email to: info@LakeShoreFuneralHome.com Family will send Obituary (and Photo) to Funeral Home Family will send Obituary (NO Photo) to Funeral Home No Obituary publicized Name of Cemetery:Cemetery Contact Information (Name, City, State, Zip Code, Phone Numbers):Is Cemetery Property Paid For:* Yes - We Paid Personally No, but will pay it ourselves No, Add it to our Funeral Bill Is Opening/Closing Paid For? If not, We need grave digger information:Is the Cemetery Endowment Fee (if any) Paid:Is a Vault/Liner Required by Cemetery: YES - Required by Cemetery NO, NOT REQUIRED- but I will purchase one NO - No Thanks What about a headstone?* Yes, I'm Interested in purchasing a headstone No Thanks Are you interested in discussing pre-planning for youself or someone else, sometime soon (but after these services are completed?*EmailThis field is for validation purposes and should be left unchanged. Δ