Membership Application & Authorization for Cremation

Registration Form

First Name:
Middle Name:
Last Name:
Telephone:
Address:
City:

(Inside City Yes No)
State:
Zip:
County:
E-mail:

Information required on the Death Certificate

Date of Birth:
Place of Birth - City:
Place of Birth - State:
Sex: M F
Race:
Hispanic: Yes No
Specify (Cuban, etc.):
Social Security #:
Education
(Grad 1-12/College 1-4 or 5+):
Usual Occupation:
Business or Industry:
Father's Name - First:
Father's Name - Middle:
Father's Name - Last:
Mother's Name - First:
Mother's Name - Middle:
Mother's Name - Maiden:
Marital Status: Married Married but Separated
Widowed Divorced Never Married
Civil Union Civil Union but Separated
Surviving Partner of Civil Union
Husband/Wife/Partner Name
(If Wife-Maiden Name):
Are you a Veteran ?: Yes No
If Yes, enclose a copy of your discharge.

Payment Plan - You are not a member until this form is on file and your registration fee is received.

I wish to register with Cremation Society™ Of Illinois, Inc.
Single $20.00 Couple $15.00 each
I wish to prepay for my Cremation and to have the money placed in trust/insurance.
Please include Driver's License Number on all Checks.
After filing, you will receive membership cards.

Next of Kin-Please list at least one (If none, primary person in charge)

Next of Kin 1:

Name:
Relationship:
Address:
City:
State:
Zip:
County:
Phone:
Email:

Next of Kin 2:

Name:
Relationship:
Address:
City:
State:
Zip:
County:
Phone:
Email:

In order that your wishes are followed, check one of the following:

I do not wish to allow any of my survivor(s) the option of cancelling my cremation and selecting alternative arrangements, regardless of whether my survivors deem a change to be appropriate.

I wish to allow only the survivor(s) who I have designated below the option of cancelling my cremation and selecting alternative arrangements, if they deem a change to be appropriate ...
If multiple names, list them separated by commas:


Obit/Death Notice

Husband/Wife/Partner:
Children:
Brother/Sister:
Grandchildren:
Great Grandchildren:

Additional Instructions If Desired