NAME: First Middle Last

ADDRESS:   Street   City State Zip     County in which the decendent lived:

Social Security: Date of Birth: Birthplace:   example: 000-00-0000   example: 00/00/0000   example: las vegas, nv

Phone Number: Other Number: Sex: Male     Female   example: 123-123-1234   example: 123-123-1234

Kind of Industry or Business: Primary Occupation:   example: Banking, Healthcare   example: Physician

Married Never Married Divorced Separated Widowed Highest Grade Completed in School Name of Spouse (even if they are deceased): (if no spouse please type "No Spouse") Full Name (maiden name)

Race: White Black Asian American Indian Other: Of Hispanic Origin: No Yes If yes, please specify: Cuban Puerto Rican Mexican Other:

FATHER'S NAME: MOTHER'S NAME: First Last   First Last (maiden name)

Veteran: No Yes, if yes you will need to provide a valid DD214

Immediate Next of Kin: Relationship: Telephone Number:   example: sister or brother   example: 123-123-1234 Address:   Street City State Zip

Primary or Secondary Person in Charge of Arrangements: Relationship: Telephone Number:   example: sister or brother   example: 123-123-1234 Address:   Street City State Zip

CHARGES: By submitting this for you understand that the charges for La Paloma Cremation and Funeral Services are due and payable prior to completion of services.

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