Imminent Need Intake Form | Dingmann Funeral Care Burial & Cremation Services

Imminent Need Intake Form

If a death will occur soon, you can fill out this form to get the planning started. This will provide us with the basic information to help simplify the process when the death occurs. You can always call us or come in the funeral home at any time along the way.

Immediate Need Form

Free Text

Personal Information of Deceased

Last Name*

Middle Name*

First Name

Date of Birth*

Date of Death*

Time of Death*

Social Security Number*

Free Text

Preparation Information

Has a Doctor / Coroner Been Notified?

Yes

If Deceased Passed at Home, Do You Permit Us to Embalm the Body?

Yes

Has the Body Been Released for Removal?

Yes

Do You Permit Us to Cremate the Body?

Yes

If Yes, Who Has Granted Permission?

Free Text

Physician Information

Name of Doctor Signing Death Certificate*

Email Address*

Business Telephone*

Street*

City*

State/Province*

Zip/Postcode*

Free Text

Personal Information of Person Legally Responsible for Disposition

Last Name:

Middle Name:

First Name*

Relationship to Deceased*

Street*

City*

State/Province*

Zip/postcode

Primary Phone Number*

Secondary Phone Number*

Best Time to Reach Via Phone*

Do You Have a Prearrangement on File with Us?

If Yes, Under What Name?

Need to speak with our team?

Immediate Need Form

SUPPORT AFTER A LOSS