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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

We are very sorry for your loss and stand ready to assist you in your time of need. If you have not already scheduled a meeting with us, please call us. PLEASE DO NOT USE THIS FORM TO NOTIFY US OF A REMOVAL NEEDING IMMEDIATE RESPONSE. THIS FORM IS NOT MONITORED 24/7. Please contact us by phone, as this form is used to PREPARE for your appointment in-office or remote arrangements by digital signature.

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.
PLEASE ALWAYS FOLLOW-UP WITH A PHONE CALL TO US, TO VERIFY WE RECEIVED YOUR INFORMATION FROM THIS FORM.

GENERAL PRICE LIST WITH CASKET PRICE LIST

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

Online Arrangements: Preliminary Form

Arrangement Information

Basic Information

How Did You Find Lafferty & Smith Colonial Chapel?

Previous ExperienceHospice Hospital Coroner Referral or ListingFriends ReferralGoogle SearchYahoo SearchYelp ReviewsOther

Planning Timeframe

If NO Death Has Yet Occurred, 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 Decedent

Who is Next-of-Kin or Legally Authorized Party?

An Advance Health Care Directive Primary AgentSpouseChild(ren)Parent(s)Sibling(s)Other

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 Deceased?

Did the Decedent Establish a Case File at the Mortuary in Advance of Need?

Type of Arrangements Desired

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

Decedent's Last Name

Decedent's First Name

Decedent's Middle Name (if applicable)

Date of Birth

Date of Death

Time of Death (if known)

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 GraduateAssociatesBachelorsMastersDoctorateProfessional/Trade Certification

Decedent Spanish / Hispanic / Latino (specify nationality of family origin or "none" - California requires we ask)

Decedent's Race (listing a nationality is not necessarily a race)

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.)

Number of Years in Occupation

Decedent's Usual Residence

Street

City

State/Province

ZIP/Postcode

Number of Years Decedent Has Lived in this County

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

Father's Full Name (including middle, if applicable)

Father's Place of Birth

Mother's Full *MAIDEN* Name (including middle, if applicable)

Mother's Place of Birth

Number of Certified Copies of Death Certificates Requested

Who Will Pick-up Death Certificates From Us?

Funeral Service Request

Place of Service / Ceremony

Place of Visitation / Viewing

Religious Denomination or Preferences (optional)

Usual Place of Worship

Lodge / Union / Association Membership

Newspapers / Obituary Notice Preferences (select any you desire)

Press DemocratPetaluma Argus CourierSonoma Index TribuneMarin Independent JournalSan Francisco ChronicleSan Jose Mercury NewsLaffertyandSmithcom free tribute on our websiteOther

Disposition Request

I Prefer

GENERAL PRICE LIST WITH CASKET PRICE LIST

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

Casket/Container Style Preference

Cremation Urn Style Preference

Place of Final Disposition, if Cremated

Does the Deceased Have a Pacemaker or Defibrillator for Their Heart?These devices can explode during cremation.

Cemetery or Whose Residence Where Remains are to be Placed

Cemetery or Residence Physical Address

Cemetery or Residence Telephone

Who Will be Authorized to Pick-up Cremated Remains?

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

Summary of Details

Additional 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? "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 not required by law."

YesNo

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

Legal Responsible Party

Last Name

First Name

Middle Name

Relationship to Deceased

Street

City

State/Province

ZIP/Postcode

Primary Phone Number

Best Time to ReachVia phone

Secondary Phone Number

Email Address

Supporting Documentation Portal

Securely upload PDF Advance Health Care Directive

Securely upload submitter's photo ID (e.g., driver's license or passport

Securely Upload Honorable Discharge / military DD form 214

Other document pertinent to arrangements (optional)

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

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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.

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