Push button for menu

Home
Low Cost Cremation
When Death Occurs
Services
Pre-Plan
- Pre-Plan
- Have The Talk of a Lifetime
Making Arrangements
About Us
Obituaries
Testimonials
Resources
Contact Us

Push button for menu

Home
Low Cost Cremation
When Death Occurs
Services
Pre-Plan
- Pre-Plan
- Have The Talk of a Lifetime
Making Arrangements
About Us
Obituaries
Testimonials
Resources
Contact Us

Making Arrangements

If a death has occurred, we are very sorry for your loss and stand ready to assist you in your time of need. Or, if you are planning future services for either yourself or someone close to you, we commend you for researching. If you have not already scheduled a meeting with us, please call us.

THIS FORM IS MONITORED PERIODICALLY DURING OFFICE HOURS ONLY and is used for both making arrangements in pre-planning for the future, or immediate needs and requests after a death has occurred. This form is used to PREPARE for your appointment in-office or remote arrangements by digital signature. It will ease your process in-office or by remote arrangements, and can be completed from the comfort of your own home.

If you prefer, you are welcome to send us information using the form below. We understand that you may not have access to all of the details below (or would prefer to provide in person). You are welcome to fill out as much or as little as you prefer. We will cover the remainder when we meet with you or speak with you by telephone. If you have difficulty completing the form, we can fill out the fields for you with a simple phone call to our office. Thank you.

GENERAL PRICE LIST INCLUDING CASKET PRICE LIST

Click on the graphic on the left to download the file.

CONSUMER GUIDE TO FUNERAL & CEMETERY PURCHASES

Click on the graphic on the left to download the file.

COMPRAS DE SERVICIOS DE FUNERALES Y CEMENTERIO

Haga clic en el gráfico de la izquierda para descargar el archivo.

GENERAL INFORMATIONAL GUIDE

Click on the graphic on the left to download the file.

Who Has the Right to Make Decisions: The Beginning

From the Health & Safety Code, Section 7100, of the State of California

DISPOSITION ARRANGEMENTS

California law identifies who has the right, duty, and responsibility to make decisions after a person’s death for disposition arrangements:

They are, in order, as listed in the law:

• A person, prior to his or her death.

• The Person Authorized to Direct Disposition (PADD) on a U.S. Department of Defense Record of Emergency Data (DD Form 93) as that form existed on December 31, 2011,or its successor form.

• An agent under a California power of attorney for health care.

• The surviving competent spouse or registered domestic partner.

• The surviving competent adult child or the majority of the surviving competent adult children.

• The surviving competent parent or parents.

• The surviving competent adult sibling or the majority of the surviving competent adult siblings.

• The surviving competent adult or the majority of the surviving competent adults in the next degree of kinship.

• A conservator of the person appointed under Part 3 (commencing with Section 1800) of Division 4 of the Probate Code when the

decedent has sufficient assets.

Preliminary Form

Arrangement Information

Basic Information

How Did You Select Our Funeral Home? (please check any that apply)

Having Already Pre-arranged ServicesPrevious ExperienceHospice, Hospital or Coroner, Referral or ListingFriend's ReferralLocal Proximity to YouGoogle SearchYahoo SearchYelp ReviewsOther

Planning Timeframe

Is There an Existing Pre-arranged File at the Mortuary?

If Distant Future Need, Are You Interested In Pre-funding Arrangements?

If NO Death Has Yet Occurred, Is Loved One Currently Receiving Hospice/Palliative Care?

Where Is the Loved One Located?

If Loved One Passed at a Facility, Please Specify Facility Name and City

Your Name

Your Telephone Number

Your Email Address (optional)

Your Relationship to the Loved One

If Making Arrangements For Another, Who Is the Next-of-kin or Legally Authorized Party?

Is There a California Advance Health Care Directive (Medical Power of Attorney)? NOTE: Pink POLST is not an AHCD.

How Many Adult Children (if applicable) Survive the Loved One?

Vital Statistics (required by CA for creating the death certificate)

Loved One's Last Name

Loved One's First Name

Loved One's Middle Name (if applicable)

Date of Birth

Date of Death (if applicable)

Time of Death (if applicable and if known, also specify A.M. or P.M.)

Decedent's Sex

Place of Birth (U.S. State or Foreign Country)

Social Security Number (or you can call it in or bring it in with you)

Decedent's Military Service

Decedent's Marital Status ("single" is not accepted)

Decedent's Highest Level of Education Completed

No Formal Education1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade, No DiplomaGEDHigh School GraduateSome College, But No DegreeAssociatesBachelorsMastersDoctorateProfessional/Trade CertificationUnknown

Decedent Spanish / Hispanic / Latino? (if yes, specify country of family history)California requires that we ask this question

Race (according to California, listing a nationality is not necessarily a race)California requires that we ask this question

Usual Occupation for Most of Life (function type or title - note: "retired" is not accepted)

Kind of Business or Industry (e.g., grocery store, road construction, employment agency, etc.)

Approximate Number of Years in Occupation

Decedent's Usual Residence (please do not enter your own unless it's the same)

Decedent's Usual Residence Address (Please provide in full)

Approximate Number of Years Residing in This County of Residence

Full Name of Surviving Spouse / SRDP (include *MAIDEN* name if female; "none" if no surviving spouse)

Father's Full Name (including middle, if applicable)Please complete this item, whether he is living or deceased

Specify Father's U.S. State of Birth (or foreign country of birth if outside of the U.S.)

Mother's Full *MAIDEN* Name (including middle, if applicable)Please complete this item, whether she is living or deceased

Specify Mother's U.S. State of Birth (or foreign country of birth if outside of the U.S.)

Number of Certified Copies of Death Certificates Requested

Who Will Be Pre-authorized to Pick-up Death Certificates From Funeral Home? (list one or more persons)

Funeral Service Requests

Type of Arrangements Desired

Place of Visitation / Viewing

Place of Service / Ceremony

Religious Denomination or Preference (optional)

Usual Place of Worship (optional)

Lodge / Union / Association Membership (optional)

Newspapers / Obituary Notice Preferences (select any you desire)

Press DemocratPetaluma Argus CourierSonoma Index TribuneMarin Independent JournalSan Francisco ChronicleSan Jose Mercury NewsOther

If You Don't See Your Preferred Newspaper, Please Specify:

Do You Permit Lafferty & Smith to Create a Free Public Memorial Webpage on LaffertyandSmith.com? (there is no cost to you)

Casket/Container Style Preference

Cremation Urn Style Preference

Other Materials or Merchandise (check all that apply)

Full Memorial Guest Register PackageGuest Book OnlyMemorial Folders OnlyPrayer Cards OnlyCrucifixRosary BeadsCremation JewelryKeepsake (sharing) Cremation UrnsBurial Garments

Disposition Request

I Prefer:

Place of Final Disposition, if Cremated

Is There a Pacemaker or Defibrillator Implanted in the Body?These devices can explode during cremation.

Cemetery Name or Whose Residence Where Remains Are To Be Placed

Cemetery or Residence Physical Address

Cemetery Telephone (if known)

Who Will be Authorized to Pick-up Cremated Remains From Us? (list one or more persons)

Summary of Details

Additional Special Instructions or Requests Before Cremation or Burial

Memorial Requests or Donations to Charity

Preparation Information

Has a Doctor / Coroner Been Notified?

YesNo

If deceased passed at home

Has the Body Been Released for Removal?

YesNo

Do You Permit Us to Embalm the Remains?

YesNo

"Embalming is the addition to, or the replacement of, body fluids by chemical preservatives or the application of chemical preservatives for the temporary preservation of the body. I understand that embalming is no required by law."

Date/Time Embalming Permission GrantedIf you DO request embalming, we are required to have you note DATE and TIME of your approval, please.

Physician Information (if known)

Name of Primary Care Physician

Business Telephone

Kaiser Medical Record Number, If Applicable (or you can call it in or bring it in with you)

Legal Responsible Party

Full Name

Relationship to Loved One

Street

City

State/Province

ZIP/Postcode

Primary Phone Number

Best Time to ReachVia phone

Secondary Phone Number

Email Address

Please select from one of the options below:

Send me information about arrangements

Contact me to set up an appointment

No appointment needed--just keep my future pre-planning requests and information on-file

Anti-Spam Security Question

Ready to Submit?

Please be sure our page CONFIRMS you have submitted the form successfully (a note will pop up below). If the form doesn't submit, please check the fields above for any "required" items pending your answer. Please remember to follow-up with a phone call to us, to verify we have received your information from this form.

Home

Home

Low Cost Cremation

Low Cost Cremation

When Death Occurs

When Death Occurs

Services

Services
General Price List
Merchandise

Veterans

Veterans Overview
Veterans Headstones
Veterans Burial Flags

Pre-Plan

Pre-Plan
Have The Talk of a Lifetime

Making Arrangements

Making Arrangements

About Us

About Us
Our Staff
Why Choose Us
Our Location
Our Calendar

Obituaries

All Obituaries

Testimonials

Testimonials

Resources

Grief Support
Funeral Etiquette
Social Security Benefits
F.A.Q.

Contact Us

A year of daily grief support

Our support in your time of need does not end after the funeral services. Enter your email below to receive a grief support message from us each day for a year. You can unsubscribe at any time.