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Legal information for person whom arrangements are being made

First Name

Date of Death

Middle Name

County of Death

Last Name

Gender

MaleFemale

Date of Birth

If less than one day old, use time

Most Recent Birthday

Social Security Numberxxx-xx-xxxx

City or Town of Birth

State or Foreign Country of Birth

Address of person for whom arrangements are being made

Street

City

State/Province

ZIP/Postcode

County

Tribal Reservation Name(if applicable)

Inside City Limits?

YesNoUnknown

Length of Time at this Residence

Other Information

Education

OccupationDo not use retired

Kind of Business/IndustryDo not use Company Name

U. S. Veteran

Marital status

Surviving Spouse or Partner's NameIf wife, please use maiden name prior to first marriage

Race or Ethnicity

Parents' Information

Father's First Name

Mother's First Name

Father's Middle Name

Mother's Last Name

Father's Last Name

Mother's Last Name (Maiden name)

Informant's Information

Informant Name

Relationship to Person Arranged For

Street

City

State/Province

ZIP/Postcode

Informant Country

Place Of Death

If Death Occurred in a Hospital

Death Occurred Elsewhere

Other

Facility Name(If not facility, omit and enter address below)

Street

City

State/Province

ZIP/Postcode

Certification

This information will be used to prepare legal documents. Powers Funeral Home will not be responsible for incorrect information. I attest the information above to be true and accurate. I understand changes and/or corrections after filing will be at my expense.

Electronic Signature

Today's Date

Contact Us

320 W. Pioneer Ave
| Puyallup, WA 98371
| Tel: 253-845-0536
| Fax: 253-845-4301

320 W. Pioneer Ave
| Puyallup, WA 98371
| Tel: 253-845-0536
| Fax: 253-845-4301
| Directions

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It is never too early to start planning for yours or your loved one's funeral.