Pre Need Planning Thank you for choosing Coastal Cremations. Please fill out the form below. Please enable JavaScript in your browser to complete this form. - Step 1 of 8Information About The Person Completing This FormI Am Planning For *Select OptionMyselfAuntBrotherCousinDaughterDaughter‐in‐lawFatherFather‐in‐lawFriendGranddaughterGrandfatherGrandmotherGrandsonGreat‐granddaughterGreat‐grandsonGreat‐ grandfatherGreat‐grandmotherHusbandMotherMother‐in‐lawNephewNieceSisterSonSon‐in‐ lawUncleWifeParentChildGrandchildSiblingOtherPlanner Name *FirstLastPlanner Phone Number *Planner Email *Planner Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNextInformation About The Person You Are Planning ForName *FirstLastMiddle NameAddress (No PO Boxes) *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneCounty *Inside City Limits?YesNoGender *Select OptionMaleFemaleRace (More than 1 may be specified) *WhiteAsian IndianAfrican American / BlackChineseAmerican Indian / Alaskan NativeFilipinoNative HawaiianGuamanianJapaneseSamoanKoreanVietnameseOther Asian (Specify)Other Pacific (Specify)Other (Specify)Specify Race *Hispanic Or Haitian Origin *YesNoSpecify Hispanic Or Haitian Origin *MexicanCentral South AmericanPuerto RicanCubanHaitianOther Hispanic (Specify)Specify Hispanic Origin *Date Of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920City Of Birth *State Of Birth *Select OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherPreviousNextAdditional Information About The Person You Are Planning ForMarital Status *Select OptionMarriedNever MarriedDivorcedWidowedSpouse's Full NameSpouse's Maiden NamePlace Of MarriageDate Of MarriageMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mother's NameMother's Maiden NameFather's NameNumber Of ChildrenPreviousNextWork And EducationEducation *Select OptionLess than High SchoolHigh School or GEDSome College. No DegreeAssociate DegreeBachelors DegreeMastersDoctorateUsual Occupation (Most Of Life) *Kind Of Business *CompanyPreviousNextMilitary ServiceWas The Person You Are Planning For Ever In The US Armed Forces? *Select OptionYesNoBranch Of ServiceSelect OptionArmyNavyAir ForceMarinesCoast GuardSelected ServiceArmy Air ForceMerchant MarineSerial NumberDate Entered ServiceMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Discharge On File AtDate Of DischargeMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Copy Of Discharge Available?Select OptionYesNoHonorable DischargeSelect OptionYesNoDo You Feel The Death Is Service ConnectedSelect OptionYesNoPreviousNextFuneral Or Memorial Service Preferences (If So Desired)Place Of ServiceSelect OptionFuneral HomeChurchCemeteryLocation of Your ChoiceAddressPhonePlace Of VisitationI Prefer The Funeral Service To BeSelect OptionPublicPrivateViewing Of FamilySelect OptionYesNoViewing Of FriendsSelect OptionYesNoReligious DenominationSelect OptionChristianityJudaismIslamBuddhismHinduismNon‐Religious/SecularWiccan/Pagan/DruidUnitarian UniversalAgnosticismAtheismOtherNonePlace Of WorshipLodge/UnionPreviousNextDisposition OptionsCremation DispositionSelect OptionCemeteryScatteringReturn to familyCemetery NameCemetery CityCemetery Location/SectionPreviousNextSpecial InstructionsFlower PreferenceMusicJewelryGlassesClothingOtherOther Information And Special InstructionsPlease List Any Other Instructions You Would Like Us To HavePreviousCommentSubmit
