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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