Connecticut Cremation Service


Direct Cremation Service, Info Form


For information needed to complete The Connecticut Death Certificate



Name___________________________________ Sex_____________ Age_________________



Date of Birth__________________________ Race____________________________________



Social Security #________________________ Years of Education________________________



City and State of Birth_____________________________ Citizen of______________________



Usual Occupation_____________________________ Kind of Industry____________________



State of Residence____________________________ County____________________________


Town_____________________________ Address____________________________________



Marital Status __________________ Name of Last Spouse (maiden)______________________



Veteran     Yes   or    No


Father’s Name______________________ Mother’s Name (maiden)_______________________


Information of Person filling out this form:


Name and Relation to Deceased____________________________________________________


Address_____________________________________ Telephone #_______________________


Cremation as Provided By Connecticut Cremation Service / New Haven Funeral Service. Transfer of deceased from place of death to holding facility for 48 hours as required by Connecticut Law. Obtain information for and secure Death Certificate, Cremation Permits, and Medical Examiners Certificates. Arrange for cremation at nearest crematory and provide a minimum cremation container. Transport deceased from holding facility to crematory.


Please fill out and send back to:

Connecticut Cremation Service / New Haven Funeral Service

1368 State Street New Haven, CT 06511
or fax 203-772-3092