Date of Birth (month/day/year) 
Social Security Number

Usual Occupation (give kind of work done during most of working life)
 

Kind of Business or Industry

Current Residence:
Street and Number
Please Select city or village of: township of:   Please Select Grand Rapids Wyoming Kentwood Grandville Lowell Comstock Park Other (specify) "other":

County  State   Zip Code

Mailing Address (if different from above)
Street and number or rural route number, city or village, state, zip code. 

Birthplace (City and State or Foreign Country)

Marital Status Please Select married never married widowed divorced
Surviving Spouse (if wife, give name before first married)

Was decedent ever in US Armed Forces? Please Select yes no

Hispanic Origin Please Select Yes No

Ancestry (Mexican, Puerto Rican, Cuban, Central or South American, Chicano, other Hispanic, Afro-American, Arab, English, French, Finnish, etc.)
 

Race (American Indian, Black, White, etc. If Asian, give nationality i.e., Chinese, Filipino, Asian Indian, etc.
 

Decedents Education
(Specify highest grade completed) Please Select 0 1 2 3 4 5 6 7 8 9 10 11 12 1 year college 2 years college 3 years college 4 years college 5+ years college

Father's Name (first, middle last)

Mother's Name
(first, middle, surname before first married)

What Clegy is to Officiate?

If Burial, what cemetery? no selection Fulton Street Oakhill Restlawn Rosedale Woodlawn Greenwood Plainfield Township Holy Cross Resurrection other Other

If Cremation is selected, what should be done with the cremains?
Family to pick up.
Mailed to: (name, mailing adress)
($30.00 CONUS mailing fee applies)
Deliver to Local Cemetery (indicate)
(no charge for local cemetery delivery)

  Other (inicate)

Register Book Selected
Basic Red $22 (included with some packages)
Dove $32
Veterans $32
Lakeshore $32

Memorial Folders $18 per 50 (included with some packages)
End of Day
Cross
Veterans
Dove

Prayer Cards $18 per 50 (included with some packages)
Traditional
Modern

Please List at least 2 Survivors (name, relationship, address, phone number)
 

Person to finalize arrangements at time of death (name, relationship, address, phone number)
 

Number of Death Certificates needed to settle legal affairs (Kent County charges $10 for the first and $3 for each additional)