Funeral Registration

Funeral Home Name REQUIRED Please fill out this field. Please enter valid data.

Funeral Director Name or point of contact for scheduling REQUIRED Please fill out this field. Please enter valid data.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Name of deceased REQUIRED Please fill out this field. Please enter valid data.

Age REQUIRED Please fill out this field. Please enter valid data.

Date of Death REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

Family point of contact REQUIRED Please fill out this field. Please enter valid data.

How is the point of contact related? REQUIRED Please fill out this field. Please enter valid data.

Family point of contact phone number REQUIRED Please fill out this field. Please enter valid data.

Service Date Requested REQUIRED Please fill out this field. Please enter a date.

Service Time Requested REQUIRED Please fill out this field. Please enter valid data.

Is a Mass requested REQUIRED Yes No Please fill out this field.

Will the body be present Yes No

Gravesite to follow after the Mass Yes No

Gravesite only REQUIRED Yes No Please fill out this field.

Has music been arranged yet REQUIRED Please fill out this field. Please enter valid data.

Name of Cemetery REQUIRED Please fill out this field. Please enter valid data.

Address of Cemetery REQUIRED Please fill out this field. Please enter valid data.

Is a Rosary being done Yes No

Is Rosary being scheduled at REQUIRED Please fill out this field.

Name of requested priest REQUIRED Please fill out this field.

Family’s language REQUIRED Please fill out this field.

Please let us know of any special requests or notes that will help us assist you in scheduling this funeral.

St. Stephen's