Get in touch

555-555-5555

mymail@mailservice.com

Services

If a Death Has Just Occurred

Immediate Need Form

Free Text

Personal Information of Deceased

Last Name*

Middle Name*

First Name*

Date of Birth*

Date of Death*

Time of Death*

Social Security Number*

Free Text

Preparation Information

Has a Doctor / Coroner Been Notified?

Yes

If Deceased Passed at Home, Do You Permit Us to Embalm the Body?

Yes

Has the Body Been Released for Removal?

Yes

Do You Permit Us to Cremate the Body?

Yes

If Yes, Who Has Granted Permission?

Free Text

Physician Information

Name of Doctor Signing Death Certificate*

Email Address*

Business Telephone*

Street*

City*

State/Province*

Zip/Postcode*

Free Text

Personal Information of Person Legally Responsible for Disposition

Last Name*

Middle Name*

First Name*

Relationship to Deceased*

Street*

City*

State/Province*

Zip/Postcode*

Primary Phone Number*

Secondary Phone Number*

Best Time to Reach Via Phone*

Do You Have a Prearrangement on File with Us?

If Yes, Under What Name?

Chavez Funeral Home - Santa Rosa

For Immediate Assistance

Call (575) 472-3369

923 S. Third Street

Santa Rosa, NM 88435-0395

GET DIRECTIONS

Chavez Funeral Home -

Fort Sumner

For Immediate Assistance

Call (575) 355-2311

830 N. Fifth Street

Fort Sumner, NM 88119-0386

GET DIRECTIONS