Request Funeral Statement Form

Your Information

First Name*:

Last Name*:

Address*:

City*:

Country*:

State/Province*:

Zip/Postal code*:

Email Address*:

Phone Number*:

Your Loved One's Information

First Name*:

Last Name*:

Please input either the complete date, month, or year, an estimated day of death.

A year is required, however, for all cases. Please input the year only in the text box below.

This does not need to be exact, but if provided, it will greatly help speed up the request process.

Date of Death *:

Date of Death*:

Where to Send Funeral Statement

I would like my Statement sent by:*:

Mail

Both

Email:

Address:

City:

Country:

State/Province:

Zip/Postal code:

If you have any additional questions, please write your question here, or email us at higgins@higginsfuneralhome.com. Thank you!

Additional Comments?

(For FEMA Submission - For Informant Only)