Riewerts Memorial Home, Inc.

Immediate Need Form

This At Need Planning Form is designed for to provide us with the necessary information needed for our records.

All of these details will assist the funeral director and staff when completing the death certificate and related matters. Acquiring this material may take some research into family records that are not readily available but will be necessary during the arrangement conference at the funeral home.

You may find it helpful to print a copy for your records and bring with you for the arrangement conference with your funeral director. CLICK HERE for further instructions and the download link, if interested.

If you have any questions whatsoever, please contact Riewerts Memorial Home, Inc. at: (201) 384-0700

Deceased Vital Statistics for Death Certificate

* First Name:
* Last Name:
Middle Name:
Sex:
Race:
Date of Birth:
Place of Birth: City:

State:

Country:
Date of Death:
City of Death:
State of Death:
County of Death:
Location of Death:

If other, please indicate address:
Name of the Place of Death:
Education
Usual Occupation (most of life):
Kind of Business:
Company:
Marital Status:
Full Name of Surviving Spouse:
If Wife, Provide Maiden Name:
Residence - Street Address:
City/Town:
Inside City Limits:
County:
State:
Zip Code:
Length of Residence In County:
Father's Full Name:
Mother's Full Maiden Name:

Type of Disposition

Disposition Will Be:
If Cremation, Indicate Preference For
Disposition of Ashes?:
Name of Cemetery (if applicable):
City:
State:

Preparation and Viewing

Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming.

Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.

The Family Preference Regarding Viewing/Embalming Is:
I Authorize Riewerts Memorial Home, Inc.
To Embalm:
Name of Authorizing Person:
Relationship To Deceased:

Veteran Information

Was Decedent Ever In the
US Armed Forces?:
Yes No (if no, continue to next section)
Branch of Service:
Date Enlisted:
Date Discharged:
Honorable Discharge: Yes No
Military Serial Number:
Is A Copy of Discharge Papers
Available?
Yes No (if yes, please bring for us to copy):

Informant/Person In Charge Information

* First Name:
* Last Name:
Relationship To Deceased:
* Email Address:
Address:
City:
State:
Zip Code:
Telephone Number:

Funeral/Memorial Service Information

Preferred Place of Service:
Religious Denomination:
Is there Immediate Need Funeral
Insurance on decedent?:
Yes No
If Yes, Specify Insurance Type:
(i.e., Forethought, Purple Cross, trust, etc.)

Other Information & Instructions

Please list any other instruction or information you would like us to have:





Immediate Need Form - Printer-friendly Version

You can download the printer-friendly version of the Immediate Need Form to your local computer from the link below. Once downloaded, open the PDF *, and enter your information on the form, then print it out on your printer. You may then either mail or fax it to us at the address or fax number below, or bring it with you when you visit.

»   CLICK HERE to download the form - choose to, 'Save to Disk,' in the dialog box that appears (download times will vary depending upon connection.)

Get Adobe Acrobat Reader* NOTE: Adobe Acrobat Reader software is required to view this file - if you don't already have the Reader installed on your computer, it is available for free from Adobe's website - please click the icon at right to be taken to the download page.

Mail completed forms to the following address:

Riewerts Memorial Home, Inc.
187 South Washington Ave
Bergenfield, NJ 07621

Please call with any questions: (201) 384-0700


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