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Arrangements Form

Making Arrangements

If a death has occurred, we are very sorry for your loss and stand ready to assist you in your time of need. Or, if you are planning future services for either yourself or someone close to you, we commend you for researching. If you have not already scheduled a meeting with us, please call us.

THIS FORM IS MONITORED PERIODICALLY DURING OFFICE HOURS ONLY and is used for both making arrangements in pre-planning for the future, or immediate needs and requests after a death has occurred. This form is used to PREPARE for your appointment in-office or remote arrangements by digital signature.

If you prefer, you are welcome to send us information using the form below. We understand that you may not have access to all of the details below (or would prefer to provide in person). You are welcome to fill out as much or as little as you prefer. We will cover the remainder when we meet with you or speak with you by telephone. If you have difficulty completing the form, we can fill out the fields for you with a simple phone call to our office. Thank you.

GENERAL PRICE LIST

Prices effective February 2, 2024 and subject to change without notice.

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CONSUMER GUIDE TO FUNERAL & CEMETERY PURCHASES

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COMPRAS DE SERVICIOS DE FUNERALES Y CEMENTERIO

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Preliminary Form

Arrangements Details

Basic Information

Which Parent-Sorensen Office Do You Request?

How Did You Select Parent-Sorensen? (please check all that apply)

Having Already Pre-arranged ServicesPrevious ExperienceHospice, Hospital, or Coroner Referral or ListingFriend's ReferralLocal Proximity to YouGoogle SearchYahoo SearchYelp ReviewsOther

Planning Timeframe

Is There an Existing Pre-arranged File at the Mortuary?

If Distant Future Need, Are You Interested In Pre-funding Arrangements?

If NO Death Has Yet Occurred, Is Loved One Currently Receiving Hospice/Palliative Care?

Where Is the Loved One Located?

If Loved One Passed at a Facility, Please Specify Facility Name and City

Your Name

Your Telephone Number

Your Email Address (optional)

Your Relationship to the Loved One

If Making Arrangements For Another, Who is the Next-of-kin or Legally Authorized Party?

Is There a California Advance Health Care Directive (Medical Power of Attorney)? NOTE: Pink POLST is not an AHCD.

How Many Adult Children (if applicable) Survive the Loved One?

Vital Statistics Information (required by CA for creating the death certificate)

Loved One's Last Name

Loved One's First Name

Loved One's Middle Name (if applicable)

Date of Birth

Date of Death (if applicable)

Time of Death (if applicable and if known, also specify A.M. or P.M.)

Sex

Place of Birth (U.S. State or Foreign Country)

Social Security Number (or you can call it in or bring it in with you)

Military Service

Marital Status

Highest Level of Education

Decedent Spanish / Hispanic / Latino? (if yes, specify country of family history)California requires that we ask this question.

Race (according to California, listing a nationality is not necessarily a race)California requires that we ask this question.

Usual Occupation for Most of Life (function type or title - NOTE: "retired" is not accepted on the death certificate)

Kind of Business or Industry (e.g., grocery store, road construction, employment agency, etc.)

Approximate Number of Years in Occupation

Decedent's Usual Residence Street Address

City

State

Zip Code

Approximate Number of Years Residing in This County of Residence

Full Name of Surviving Spouse / SRDP (include *MAIDEN* name if female; "none" if no surviving spouse)

Father's Full Name (including middle, if applicable)

Father's U.S. State or Foreign Country of Birth

Mother's Full *MAIDEN* Name (including middle, if applicable)

Mother's U.S. State or Foreign Country of Birth

Number of Certified Copies of Death Certificates Requested

Who Will Be Pre-authorized to Pick-up Death Certificates From Funeral Home? (list one or more persons)

Funeral Service Requests

Type of Arrangements Desired

Place of Visitation / Viewing

Place of Service / Ceremony

Religious Denomination or Preference (optional)

Usual Place of Worship (optional)

Lodge / Union / Association Membership (optional)

Newspapers / Obituary Notice Preferences (select any you desire)

Press DemocratPetaluma Argus CourierSonoma Index TribuneMarin Independent JournalSan Francisco ChronicleSan Jose Mercury NewsOther

If You Don't See Your Preferred Newspaper, Please Specify:

Do You Permit Us to Create a Free Public Memorial Webpage on ParentSorensen.com? (there is no cost to you)

Container Style Preference

Cremation Urn Style Preference

Other Materials or Merchandise (check all that apply)

Full Memorial Guest Register PackageGuest Book OnlyMemorial Folders OnlyPrayer Cards OnlyCrucifixRosary BeadsCremation JewelryKeepsake sharing Cremation UrnsBurial Garments

Do You Permit Us to Embalm the Remains?

YesNo

"Embalming is the addition to, or the replacement of, body fluids by chemical preservatives or the application of chemical preservatives for the temporary preservation of the body. I understand that embalming is no required by law."

Date AND Time Embalming Permission GrantedIf you DO request embalming, we are required to note DATE and TIME of your approval, please.

Disposition Requests

I Prefer:

Place of Final Disposition, if Cremated

Is There a Pacemaker or Defibrillator Implanted in the Body?These devices can explode during cremation.

Cemetery Name or Whose Residence Where Remains Are To Be Placed

Cemetery or Residence Physical Address

Cemetery Telephone (if known)

Who Will Be Pre-authorized to Pick-up Cremated Remains From Funeral Home? (list one or more persons)

Summary of Details

Additional Special Instructions or Requests Before Cremation or Burial

Memorial Requests or Donations to Charity

Physician Information (if known)

Name of Physician

Business Telephone

Kaiser Medical Record Number, If Applicable (or you can call it in or bring it in with you)

Legal Responsible Party

Full Name

Relationship To Loved One

Street

City

State/Province

ZIP/Postcode

Telephone

Email Address

Please select from one of the options below:

Send me information about pre-arrangements

Contact me to set up an appointment

No appointment needed--just keep my future requests and information on file

Anti-Spam Security Question

Parent-Sorensen Mortuary and Crematory | 850 Keokuk St, Petaluma, CA 94952 | (707) 763-4131

Parent-Sorensen Mortuary | 301 S Main St, Sebastopol, CA 95472 | (707) 829-5433

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