(732) 462-0101

mail@claytonfuneralhome.com

100 Elton-Adelphia Road (Rt. 524), Freehold Township, NJ 07728

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Online Arrangement Form

Arrangement Form

Vital Statistics

First Name*:

Last Name*:

Residence*:

City/Town*:

Zip code*:

County:

Geographical History:

Date of Birth:

Social Security #:

Age:

Birthplace:

Citizen:

Sex:

Check one or more boxes to indicate what race you consider yourself to be.

Race

Race:

Black or African American

White

American Indian or Alaska Native (enrolled or principal tribe)

Asian Indian

Filipino

Korean

Chinese

Japanese

Vietnamese

Other Asian (specify)

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander (specify)

Other (specify)

Domestic Status

Domestic Status :

Check one or more boxes that best describe if you are Spanish/Hispanic/Latino.

Check 'No' box if you are not Spanish/Hispanic/Latino

Hispanic Origin

Hispanic Origin:

Highest degree or level of school completed

Education

Education:

Family Information

Spouse (if wife, maiden name):

Spouse’s Social Security #:

Spouse's Date of Birth:

Father's Name:

Mother's Name (maiden):

Veteran?:

If the answer is yes, you will need a copy of the veteran's Form DD-214 to obtain any verterans benefit, such as burial in a veteran's Cemetery, or Military Honors at the funeral.

War:

VA Pension/Disability:

Occupation:

Employer:

Type of Business:

Years Employed:

Started:

Retired:

Informant Information

Informant First Name:

Informant Middle Name:

Informant Last Name:

Relationship:

Email:

Address 1:

Address 2:

City

Country

State/Province

Zip/Postal code

Phone:

Mailing Address

Address:

City:

Country:

State/Province:

Zip/Postal code:

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Terms & Conditions

100 Elton-Adelphia Road | Freehold Township, NJ | Phone: (732) 462-0101 | Fax: (732) 462-1536 | Email: mail@claytonfuneralhome.com

Robert C. McGirr - Owner & Manager - N.J. License #3273

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