Immediate Need | Briceland Funeral Service, LLC

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Personal Information

Decedent's Legal Name (First, Middle, Last) (include AKA's if any)

If Female, Decedent's Last Name Prior to First Marriage

Sex

Social Security Number

Date of Birth

Birthplace (City and State or Foreign Country)

Marital Status

Surviving Spouse (if wife, give name prior to first marriage)

Decedent's Usual Occupation (kind of word done during most of working life.) (Do not use retired)

Kind of Business/Industry

Was Decedent Ever in U.S. Armed Forces

Yes

No

Residence-State

County

City or Town

Street and Number

Zip Code

Inside City Limits

Yes

No

Decedent's Education (Check the box that best describes the highest degree or level of school completed at the time of death))

8th Grade or Less

9th-12th Grade; No Diploma

High School Graduate or GED Completed

Some College Credit but No Degree

Associates Degree (e.g., AA, AS)

Bachelor's Degree (e.g., BA, AB, BS)

Master's Degree (e.g., MA, MS, MEng, MSW, MBA))

Doctorate (e.g., PhD, EdD) or Professional Degree (e.g., MD, DDS, DVM, LLB, JD)

Decedent of Hispanic Origin (Check box that best describes whether the decedent is Spanish/Hispanic/Latino. Check "No" box if the decedent is not Spanish/Hispanic/Latino.)

No, not Spanish/Hispanic/Latino

Yes, Mexican, Mexican American, Chicano

Yes, Pueto Rican

Yes, Cuban

Yes, other Spanish/Hispanic/Latino

Specify

Decedent's Race (Check one or more races to indicate what the decedent considered himself or herself to be)

Other Asian (Please Specify)

Other Pacific Islander (Specify)

Other (Specify)

American Indian or Alaska Native (Name of the enrolled or principal tribe)

Father's Name (First, Middle, Last)

Mother's Name Prior to First Marriage (First, Middle, Last)

Informant's Name

Relationship to Decedent

Mailing Address (Street and Number, City, State, Zip Code)

If a Death Has Just Occurred

Online Preplanning Form

A Year of Grief Support

If a Death Has Just Occurred

Online Preplanning Form

A Year of Grief Support

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