Full Legal Name Sex Date of Birth Place of Birth Marital Status Social Security # Race Citizen of what Country Residence Address County City State Zip Phone Email Spouse (full name prior to any marriage) Father’s Name Mother’s Name Maiden Name Next of Kin Relationship Residence Address County City State Zip Phone Email Highest Degree of Education Occupation (Do not use retired) Business/Industry (Do not use company name) Were you in the Armed Forces? Branch Serial Number Date Enlisted Place of Enlistment Date Discharged Rank at Discharge Name of Wars Choose a Package When you plan in advance, you are making choices now based on your wishes as to how your final arrangements will be carried out. Thus, you can reduce family concerns at the time of your death. Simple Dignified Cremation $1195, Member* $1295, Non Member* Just the basics, no extras - everything you need to provide for the cremation process in the most cost effective manner. Honoring Our Veterans Service $1395, Member* $1595, Non Member* An affordable tribute for the men and women that have proudly served our country. Cemetery Graveside Service $1495, Member* $1695, Non Member* Everything you need to complete the cremation process and arrange for a digni- fied committal service for the cremated remains. Celebration of Life Service $1695, Member* $1895, Non Member* Everything you need to complete the cremation process and arrange for a memo- rial service that helps to celebrate the life that was lived. All packages include: Professional Services - Services of licensed professional staff Transfer of Decedent - Transfer from place of death (35 mile radius) Refrigeration - Use of refrigeration (24 hr period) Cremation Fee Basic Cardboard Container Temporary Container (Each of these packages includes an alternative container for the cremation process and a temporary container for the cremated remains. The packages do not include medical examiner fees, certified copies of the death certificate or applicable sales tax) *These prices are effective November 1, 2012 and are subject to change without notice. Member Information Please fill out the necessary information, and we will keep it in our records. The information requested below is required to complete an Iowa Certificate of Death and must be completed. When Death Occurs When a death occurs our staff is available 24 hours a day. You are welcome to use our website to select from various options and provide needed information. However, it is imperative that you call us at (515) 331-6538 to let us know the death has occurred. A few things to remember: One of the reasons Des Moines Cremation costs less than tradi- tional funeral homes is that we have no facilities for visitations or viewings. What does this mean to you now that a death has occurred? Take your time saying goodbye to your loved one. Give other family members the option of coming to the place of death to be with you. Call us when you are ready, and we will receive your loved one into our care. Before we proceed with the cremation process, we will need vital statistic information for legal documents such as death cer- tificate and social security notification. We will also need to secure authorization for the cremation from the next of kin. This can be done on our website, over the phone and via fax, or by meeting at our West Des Moines arrangement office. Our funer- al director will contact you by telephone to review the informa- tion or set an appointment time. Once the proper authorizations, permits and payments have been obtained, we will proceed with the cremation process. The cremated remains can be mailed to you, delivered in our service area, or picked up at our West Des Moines arrangement office. This process takes approximately a week to ten days. Visit our website to learn more about our "Peace of Mind" process, service options, urn choices, obituaries and answers to many frequently asked questions. DesMoinesCremation.com