I would like an appointment with:

1 Lawrence Street
Spring Valley, NY

139 Stage Road
Monroe, NY

Pre-arrangements or at need arrangements to be made in the comfort of my residence or office 3 Hudson Street, Chester, NY
Time: Day: Month: Year:

Deceased First Name:
Deceased Middle Name:
Deceased Last Name:
Place of death:
Time of death:
Legal (Street) address:
City, State, Zip code:
Date of Birth:
Age:
City and State of Birth:
Social Security Number:
Veteran (bring discharge paper):
Occupation (Do not put retired):
Type of Business:
Number of years of Education:
Spouse's FirstName:
Spouse's Last Name (Maiden):
Father's First Name:
Father's Last Name:
Mother's First Name:
Mother's Last Name (Maiden):
Doctor's Name:
Doctor's Phone Number:
Last Date Seen by Doctor:
Name of Cemetery:
Street Address of Cemetery:
City, State, Zip code of Cemetery:
Person making the Arrangements:
Your relationship to the deceased:
Your Phone Number:

Suggested Hours of Visitation:

Monday through Friday within the hours of 3:00pm-8:00pm,
Sunday within the hours of 2:00pm-6:00pm
We will call you to confirm an appointment.




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