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OBITUARIES
OUR LOCATION
ABOUT US

Online At-Need Form

If you have any questions, or would like assistance with this form, please call or text (920) 748-2623.

Online At-Need Form

Section 1

Informant or Next of Kin Information

First Name*

Last Name*

Phone Number*

Email Address*

Home Address*

Line 2

City*

State*

Zip Code*

Decedent's relationship to you?*

Spacer 0

Section 2

Personal Information of Decedent

First Name*

Middle Name

Last Name*

Maiden Name

Date of Birth*

Social Security Number

Primary Address*

Line 2

City*

State*

Township (if applicable)

County*

ZIP Code*

City of Birth*

State of Birth*

Did the decedent serve in the military?*

Yes

No

If 'Yes', which branch?

Which race or ethnicity best describes the decedent?*

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple Ethnicity / Other

If Multiple or Other, Please Specify

Is the decedent of Hispanic origin?*

Yes

No

Decedent's Father's Full Name*

Decedent's Mother's Full Name*

Decedent's Mother's Maiden Name*

Marital Status*

Spouse's Name (if applicable)

Spouse's Maiden Name (if applicable)

Place of Marriage

Date of Marriage

Free Text

Education History

Highest Level of Education*

School Name

School Location

Free Text

Work History

Occupation*

Type of Industry*

Wishes

Wishes

Is burial or cremation preferred?

Burial

Cremation

Opt-In

Private viewing prior to cremation?

Visitation Options

Visitation at Funeral Home

Visitation Elsewhere

No Visitation

Funeral Service Options

Funeral Service at Funeral Home

Funeral Service Elsewhere

No Funeral Service

Final Disposition

Ground Interment (burial)

Mausoleum Entombment (above ground burial)

Columbarium (for cremation urns)

Ashes returned to family

Free Text

Preferences

Please list any musical selections to include in the services.

Please list any interests or hobbies to include in the obituary.

Survivors: Names, Their Spouses, Their City & State

Preceded in Death By: Names & Relationships

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Contact Us

515 Mayparty Dr | PO Box 371
Ripon, WI 54971

Phone | Text: (920) 748-2623
Toll Free: (888) 801-8111

Email : info@ButzinMarchant.com

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