Address: 1289 Forest Avenue, Suite A, Staten Island, NY, 10302, US
Telephone: (718) 887-8168

The following information will be used for completion of all legal documents. Including, but not limited to, certified death certificates, cremation permits, social security notification and veteran claim forms. Required fields are marked with an "*".

Step 1 of 5

Designation of Intentions Form 2 of 5
Required fields are marked with an *
Customer's Designation of Intentions
Place of Cremation
Scheduled Date of Cremation
MM slash DD slash YYYY
Authorizing Party:
- Copy information from Informant
Name
Address
Street Address City State ZIP Code
Telephone
Relationship to Deceased
Direction for Disposition of Cremains:
1. Return to
2. Burial in

Cemetery
3. Placement in Niche at

Cemetery
4. Other
Cremains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this firm, in the following manner of disposition: Scatter at sea.
Dated
MM slash DD slash YYYY
Signature of Authorizing Party*

Application for Cremation Permit Form 3 of 5
To the Office of Vital Records, Department of Health, The City of New York, State of New York
Country of
} SS. (namely or particularly)
being duly sworn deposes and says that
- he
- she
Resides at
Street Address City State ZIP Code
and desires that a permit be issued by the Department of Health of the City of New York for the cremation of the body of
Deceased Name
who died at
on
MM slash DD slash YYYY
Deponent's assumption of authority to act is based upon the following:
Deponent further states that the deceased
- did
- did not
express during life the desire to have
- his
- her
remains cremated and
- his
- her
relationship to deceased is
Deponent assumes all responsibility for the cremation of the remains and authorizes
a licensed funeral director, to make arrangements for said disposal.
Subscribed and sworn to before me this
MM slash DD slash YYYY
Signature of Informant*
Enter Name Again to Confirm*

Vital Information Form

Step 1 of 5

Vital Information Form 1 of 5

Under 1 Year

Under 1 Day

Place of Death

Designation of Intentions Form 2 of 5

Application for Cremation Permit Form 3 of 5

Confirmation of Identification Without Viewing Form 4 of 5

Part I. To be completed by Funeral Home representative whenever there is no visual identification

Part II. To be completed by next of kin or other legally authorized persons making arrangements

At-Need Written Statement of Agent Claiming Legal Control of Disposition Form 5 of 5

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