Intake - Sommerville Funeral Services

Step 1 of 10

Lets Get Started

Your Name

First Last

Phone

Personal Information (Deceased)

Name of Deceased

Prefix First Middle Last Suffix

Enter the name of the loved one who passed away

Gender

Race

Date of Birth

Date of Death

Time of Death

City and State of Birth

City State / Province / Region

Father's Name

Prefix First Middle Last Suffix

Mother's Name (w/Maiden)

Prefix First Middle Last Suffix

Social Security Number

formatted (000-00-0000)

Level of Education

Place of Death

City State / Province / Region ZIP / Postal Code

County

Care Facility

Care Facility Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Usual Address of Deceased

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County

Doctor To Sign Death Certificate

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Contact

Family Contact Same as Spouse

Yes

Name of Family Contact

First Last

Relationship to Deceased

Phone

Informants Address (Family)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Informants Email

Body Transfer Service

Are you Transferring from Another Funeral Service Location?

Yes

Transfer Location Name

Transfer Location Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you Transferring to Another Funeral Service Location?

Yes

Transfer Destination Name

Transfer Destination Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Transfer

Expected Arrival

Transportation

Sprinter

Please enter a number from 0 to 20.

Hearse

Please enter a number from 0 to 20.

Van

Please enter a number from 0 to 20.

Police Escort

Please enter a number from 0 to 20.

Limos

Please enter a number from 0 to 20.

Total Escorts

Driver Route

Pickup Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Memorial Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gravesite, Cemetery, Place of rest

Notes for the Driver

Client Intake Form

Lets Get Started

Personal Information (Deceased)

Marital Status

Family Contact

Veteran Status / Occupation

Body Transfer Service

Funeral / Memorial Services

Transportation

Driver Route

Memorabilia & Keepsakes

Memorial Program Information

Define Program Header

Service Information

Obituary

Order of Service

Poem

Program Images