Funeral Intake Form

I’m very sorry for your loss. Completing the form below will help me in working on the funeral details for your loved one.

Complete this form to the best of your ability.

Name of person completing this form(Required)

First Last

Your contact cell phone number(Required)

(for emergency contact)

Name of deceased(Required)

First Middle Last

Hebrew name of deceased (if known)

Date of birth of deceased

Date of death of deceased

Cause of death

Name of spouse or partner (whether living or dead)

First Last

If applicable, number of years together or married

Children of Deceased

First Name

Last Name

Spouse/Partner of Child if married

(If more than one child, click the (+) button to add lines)

Grandchildren of Deceased

First Name

Last Name

Spouse/Partner of grandchild if married

(If more than one child, click the (+) button to add lines)

Siblings of Deceased

First Name

Last Name

Spouse/Partner of sibling if married

(If more than one child, click the (+) button to add lines)

Funeral Details

Date of Funeral(Required)

Time of Funeral Start(Required)

:

Location of Funeral(Required)

Funeral home or cemetery name Street Address City State / Province / Region

Do you want "K'riyah" (the practice of wearing a black ribbon on your clothes to signify you are a mourner) for your immediate family?(Required)

Yes

No

Not sure

Do you need a Shiva minyan conducted after the funeral?(Required)

Yes

No

Not sure

Address

Name of family hosting the Shiva minyan Street Address City State / Province / Region

What days/times do you need a shiva minyan conducted by a member of the clergy?

Speaker and Eulogy Details

Do any family members wish to deliver words or a eulogy?(Required)

Yes

No

Not Sure

Who will be speaking (list speakers in order if more than one)

First Name

Last Name

Relation to the Deceased

(If more than one speaker, click the (+) button to add lines)

Brief biography of the deceased, including location of birth and upbringing, education, childhood details

Describe their relationships (partner/spouse: how and when they met; having a family and/or pets; strong friend relationships)

How would you describe the deceased's personality?

What occupation and organizations were the deceased associated with?

(ex: Nurse practitioner, member of the Rotary Club)

What were some of the deceased's favorite pastimes?

How did the deceased identify spiritually?

(describe their Jewish identity, relationship to the Jewish community, observance of holidays, etc)

Funeral Intake Form

Complete this form to the best of your ability.

Funeral Details

Speaker and Eulogy Details

The Mourner’s Kaddish

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