Direct Cremation Service

For information needed to complete The Connecticut Death Certificate

Name___________________________________ Sex_____________ Age_________________

 

Date of Birth__________________________ Race____________________________________

 

Social Security #________________________ Years of Education________________________

 

City and State of Birth_____________________________ Citizen of______________________

 

Usual Occupation_____________________________ Kind of Industry____________________

 

State of Residence____________________________ County____________________________

Town_____________________________ Address____________________________________

 

Marital Status __________________ Name of Last Spouse (maiden)______________________

 

Veteran Yes or No (Circle one) War_________________ Branch of Service____________

Fatherís Name______________________ Motherís Name (maiden)_______________________

Information of Person filling out this form:

Name and Relation to Deceased____________________________________________________

Address_____________________________________ Telephone #_______________________

Cremation as Provided By Connecticut Cremation Service. Transfer of deceased from place of death to holding facility for 48 hours as required by Connecticut Law. Obtain information for and secure Death Certificate, Cremation Permits, and Medical Examiners Certificates. Arrange for cremation at nearest crematory and provide a minimum cremation container. Transport deceased from holding facility to crematory.

Please fill out and send back to:

Connecticut Cremation Service 1368 State Street New Haven, CT 06511