Final Arrangements
Vital Statistics

Funeral Consumers Assoc. (FCA)
of Tampa Bay

Complete this form. Keep the original but send copies to the affiliated Funeral Home, the Funeral Consumers Assoc. (FCA) of Tampa Bay and to others deemed appropriate (all of the children, guardian, trustee, lawyer, clergy, doctor, etc.).

Please print or type all information on the line above the information request.

Member:

Full Name (first, middle, last)


Address


City, State, Zip


Phone #
Next of Kin or Contact Person:

Name and Relationship


Address


City, State, Zip


Phone #
Disposition Options:
_____   In addition to the option checked below, I wish to donate my organs as needed.
Cremation
_____   I desire Cremation of Remains and that there be no specific disposal of ashes with the understanding that per Florida Statute 470.0255, cremated remains not retrieved by the responsible party within 120 days may be scattered at sea.
_____   I desire Cremation of Remains and, because I am a veteran, that the ashes be forwarded to the U.S. Navy or U.S. Coast Guard for scattering at sea.
_____   I desire Cremation of Remains and that the ashes be delivered to:


Name


Address


City, State, Zip


Phone #
Burial
_____   I desire Burial of Remains in:


Cemetery


Address


City, State, Zip
Out of State Shipment
_____   I desire that Remains be Shipped to:


Funeral Home


Address


City, State, Zip


Phone #
Donation to Science
_____   I desire that my body be used for Medical Research. I understand that my estate will be responsible for the transportation fee to the medical facility. [Webmaster's note: Donating one's body to Science involves an additional transportation fee to Gainesville of about $200.] If you select this option, you must select a second choice above, in case the medical school will not accept your body at the time of death.
Church or Clergy Preferences:

Name


Address


City, State, Zip


Phone #
_____   I desire a Service with remains present at extra cost.
_____   I desire a Service without remains.
_____   I desire No Service.
Memorial Gifts should go to:

Name


Address


City, State, Zip
Additional Instructions:

 


 


 


 
Vital Statistics:

We often assume that our survivors know more about us than they really do! Here is a list of the ahead-of-time information required for a Death Certificate in Florida, military funeral benefits and obituary write-ups. Note that there are two sections: one for the Member and one for the Spouse.

Member Information:



Maiden Name (if female)


Marital status:


Social Security Number


Date of Birth (month, day, year)


Birthplace (city, state, country)


Your Usual Occupation (when you worked)


Kind of Business/Industry (where you worked)


Are you of Hispanic or Haitian origin? (Yes or No - If Yes, specify Haitian, Cuban, Mexican, Puerto Rican, etc.)


Specify Your Race (American Indian, Black, White, etc.)


Specify Highest Grade completed: "Elementary/Secondary" (0-12) or "College" (1-5)


Father's Full Name (first, middle, last)


Mother's Full Maiden Name (first, middle, last)


Moved Here Date


Moved From


Survivors (by Name or Number - like Number of Grandchildren)

 


 
If you were in the Armed Forces, please answer the following nine questions:


Branch of Service (Army, Navy, Air Force, National Guard, Coast Guard, Merchant Marine, etc.)


Serial Number


Highest rank


Medals & Decorations Received


Enlistment date


Enlistment station


Discharge date


Discharge station


Type of Discharge (Honorable, Dishonorable, Medical, etc.)


Spouse Information:



Name (first, middle, last) If wife, maiden name.


Social Security Number


Date of Birth (month, day, year)


Birthplace (city, state, country)


Father's Full Name (first, middle, last)


Mother's Full Maiden Name (first, middle, last)

If your spouse was in the Armed Forces, please answer the following nine questions:


Branch of Service (Army, Navy, Air Force, National Guard, Coast Guard, Merchant Marine, etc.)


Serial Number


Highest rank


Medals & Decorations Received


Enlistment date


Enlistment station


Discharge date


Discharge station


Type of Discharge (Honorable, Dishonorable, Medical, etc.)

Declaration:

I do hereby declare the above to be my wishes. I understand that I, my successors, or my designated agent must contact/contract with the funeral agency selected by the Funeral Consumers Assoc. (FCA) of Tampa Bay for the services indicated. I have placed copies of this declaration (1) among my personal papers; I have discussed my wishes and have distributed copies of this declaration to (2) my spouse, (3) my children, (4) my health care surrogate, (5) my primary care physician, (6) my attorney, (7) my clergy, and/or (8) my guardian; and have delivered a copy to (9) the contracted Funeral Home and (10) the FCA of Tampa Bay. (As a service, the FCA of Tampa Bay will endeavor to retain a copy of this declaration.)

Note that two witnesses are required!



Declarant's Legal Signature and Date


Declarant's Name - Printed


Witness #1's Signature


Witness #1's Name - Printed


Witness #2's Signature


Witness #2's Name - Printed


Home Forms Back Next Form