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At-Need Arrangement Form

Time of Death Information Form

Information About Your Loved One:

Full Legal Name of the Deceased (Indicate Title and/or Suffix, Sr., Jr.):

Name By Which He/She Is Commonly Called:

Deceased Person's Address for the Past Six Months:

Street

City

State/Province

ZIP/Postcode

If Decedent Is A Woman, Please Identify Her Maiden Name (Prior to marriage):

Decedent's Date of Birth:

Decedent's City & State of Birth:

Decedent's Race:

White CaucasianAfrican AmericanAmerican IndianHispanicAsianOther

If Decedent Is Other, Please Indicate:

Decedent's Social Security Number (Required for Death Certificate):

Decedent's Marital Status At Time of Death:

MarriedWidowedSingle (Never Married)Divorced (Not Remarried)

If Married, Full Legal Name of Spouse:

If Decedent is A Man, Maiden Name of Wife (Last name prior to marriage):

Wedding Date:

City & State of Wedding:

Full Name of Decedent's Father:

Full Name of Decedent's Mother (Include her maiden name):

Decedent's Highest Level of Education:

8th Grade or Less9th-10th Grade (No Diploma)High School Graduate or GED CompletedSome College (No Degree)Associate's DegreeBachelor's DegreeMaster's DegreeDoctorate

Decedent's Occupation (Current or Pre-Retirement):

Type of Business or Industry:

Employer Information:

Did Decedent Ever Serve in the Military:

YesNo

If A Veteran, Indicate Military Branch & War Era:

Do You Have Copies of Decedent's DD-214 or Honorary Discharge Documents:

YesNo

Decedent's Church Affiliation:

How Many Copies of Original Death Certificates Will You Need:

Information About Your Funeral or Memorial Services:

What Kind of Service Would You Like to Have:

Direct BurialDignity Direct CremationCremation with Visitation OnlyCremation with Memorial Service OnlyCremation with Visitation Memorial ServiceTraditional Chapel Service BurialTraditional Church Service BurialGraveside Service

If Service Is to be Held in A Church, Indicate Name & Location:

List A First, Second & Third Service Date Request (Note there is additional cost for Saturday services):

Name of Cemetery (Include City & State):

If Veteran, Is Burial in A National Cemetery:

Fort Smith National CemeteryFayetteville National CemeteryArkansas Veterans Memorial Cemetery (N. Little Rock)Other

If Other, Indicate Veterans Cemetery (Include city & State):

List the Names of Ministers & Speakers for the Service:

List the Names of Singers & Musicians (If any):

List Titles & Artists to Pre-Recorded Songs You Wished Played During the Service:

List Active Pallbearers (At least six persons to transport the casket):

List Honorary Pallbearers (These do not transport the casket):

Do You Want Humphrey Funeral to Produce a Video Life Tribute of Your Loved One (Additional Charge):

YesNo

Do You Want Humphrey Funeral to Live-Stream and/or Record the Chapel Service:

YesNo

Information for Decedent's Obituary:

Newspapers to Publish Obituary (Additional Charges):

Courier News (Russellville)Arkansas Democrat-Gazette (Central Zone)Arkansas Democrat-Gazette (Northwest Zone)Yell County RecordOther

If Other, Indicate Newspaper Name, City & State:

List Organizations, Leadership Roles, Church Ministries, etc., Your Loved One Was Involved In:

List Hobbies, Interest & Accomplishments of Your Loved One:

Other Information to Personalize Your Loved One's Obituary:

List Your Loved Ones Survivors (Include Name, Spouse First Name, Relationship, City & State):Include spouse, children, grandchildren, great grandchildren, siblings

List Your Loved One's Pre-Decedents (Those who died prior to his/her death):

Do You Want to Invite Memorial Donations (Indicate Name of Organization):

Finalizing Your Arrangements:

Does the Decendent Have A Pre-Paid, Pre-Arrangement Plan with Humphrey Funeral Service:

YesNo

Does the Decedent Have an Arkansas Burial Association Policy through Humphrey Funeral Service:

YesNo

Is the Decedent Covered Under a Current Life Insurance Policy:

YesNo

If Yes, Indicate Name of Insurance Company, Policy Number and Face Value:

List the Beneficiary(s) of Above Policy:

How Are You Prepared to Pay Any Balance Due on Funeral Services:

Cash or CheckDebit or Credit Card (3.5% Processing Fee)Apply for Loan Through LendingUSA

Note: Humphrey Funeral Services do not provide an in-house payment plan.

General Information:

Who Is Designated as the Informant (Immediate Next-of-Kin or other; include full name & relationship):

Street

City

State/Province

ZIP/Postcode

Good Email Address(s) for the Family:

Name of Person Completing This Online Form:

Telephone

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