Immediate Need Services in Souderton, PA | Anders-Detweiler Funeral Home & Crematory

Immediate Need Form

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Personal Information

First Name

Middle Name

Last Name

Maiden Name

Nickname(s) / AKA

Sex

Email

Date of Birth

City/State of Birth

County of Birth

Age

SS #

Alternative/Cell Phone #

Origin/Nationality/Lineage

Former residence? List towns and state

Are you an organ donor

Yes

No

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Address

Street

City

State

County

Zip Code

Township/Boro

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Mailing address different? List below

Street

City

State

County

Zip Code

Township/Boro

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Place of Worship

Name

Denomination

Street

City/State

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Education

Primary/Secondary (highest grade completed)

How many years of college?

Name of High School

Location

Name of college(s)

Location

Any degrees? List Here.

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Employment

Main Occupation

Self-employed?

Name of the business

Type of industry?

Address/Location

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If NOT self-employed, fill out information below

Business/Employer

Full Address

Kind of Business/Industry

Total length of time worked at this job?

Retired from this job?

Date/Year of retirement?

Other occupations? List below chronologically in order as they happened in life.

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Family Information

Father’s First Name

Middle Name

Last Name

Is Father deceased?

Mother’s First Name

Middle Name

Last Name

Maiden Name

Is Mother deceased?

Spouse’s First Name

Middle Name

Last Name

Maiden Name

Email

Date of Birth

If deceased, Date of Death

Place of Death

Place of Burial

Marital Status

If married, marriage place

Date of Marriage

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Informant

Is the informant the same as the spouse?

Informant’s Name & Address

Title

First

Middle

Last

Relation

SS #

Street

City

State

Zip Code

Phone #

Email

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Responsible Party

Is the responsible party the same as spouse?

Is the responsible party the same as informant?

Responsible Party’s Name & Address

Title

First

Middle

Last

Relation

SS #

Street

City

State

Zip Code

Home Phone #

Email

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Survivors (include children, grandchildren, great-grandchildren, brothers & sisters)

Please include FULL NAME, relation, spouse/partner’s name, town/state they reside, phone #/email.

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Preceeded in Death (include all relations; except for Spouse & Parents)

Please include FULL NAME and relation.

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Memberships/Organizations

Memberships (church, fraternal organizations, etc.)

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Memorial Contributions

Contributions to which organization(s)?

Do you want memorial contributions “IN LIEU” of flowers?

If you would like flowers, please designate a floral designer to use

If you do NOT choose a florist, we use our local florist ‘Frederick’s Flowers’ in Souderton

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Hobbies/Interests

He/she enjoyed…

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Viewing/Visitation Information

Will the viewing be at the Anders-Detweiler Funeral Home?

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If viewing is NOT at the funeral home, fill out information below

Location

Date/Day

Time

Will the viewing be private?

What type of viewing will it be? (Private, Public, Wake, or Vigil)

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Service Information

Will the service be at the Anders-Detweiler Funeral Home?

If service if NOT at the funeral home, fill out information below

Location

Date/Day

Time

Will the service be private?

What type of service will it be? (Funeral, Memorial, Graveside, or Mass)

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Disposition

What type of disposition will it be?

(Burial, Cremation, Removal, Entombment, Donation, Inurnment, Other (describe))

Grave Location

If burial, will the burial be private?

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(Pennsylvania Law requires embalming for: crossing state lines, a PUBLIC viewing, any type of viewing after 24 hours from the time of death or sending someone via common carrier)

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Veteran's Information

Was the deceased a veteran?

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If you are a veteran, fill out information below

Branch

(Army, Navy, Air Force, Marines, Coast Guard, Other (describe))

Enlistment Date

War

(Spanish American, WWI, WWII, Korean Conflict, Post 1/55, Vietnam, Other (describe))

Highest Rank Attained

Discharge Date

Discharge Place

Is embalming authorized?

Service #

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Embalming

Name of who authorized

Brothers & Sisters) List FULL NAME, relation, spouse/partner’s name, town/state they reside, phone #/email

Relation

Date authorized?

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Other Information

Other details?

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Any special requests?

Special requests?

Information Form

Immediate Need Form

Anders-Detweiler Funeral Home & Crematory