82 Fairview Ave.
Naugatuck, CT 06770
Phone: 203-729-4334
Fax: 203-729-4336

Immediate Need

If you have immediate need of our services, we're available for you 24 hours a day.

Obituaries & Tributes

It is not always possible to pay respects in person, so we hope that this small token will help.

Order Flowers

Offer a gift of comfort and beauty to a family suffering from loss.

Advanced Planning

A gift to your family, sparing them hard decisions at an emotional time.

Vital Statistic Information

All the information that is gathered in this form, is required to properly complete the State of Connecticut death certificate.

 

Full Legal Name:

Date of Birth:

Place of Birth (City and State):

If born outside the U.S. please list country:

Full address of Legal Residence:

Social Security Number:

Occupation prior to retirement(Type of work):

Name of Business or type of industry:

Father's Full Name:

Mother's maiden name:

Marital Status:

If married, spouse's maiden name:

Highest level of education:

Armed Forces: Yes No If yes, Branch: Conflict:

Race: Specify:

Of Hispanic origin: Specify:

Primary Care Physician Name:

Primary Care Physician number:

Primary Care Physician address:

 

 

This Next section of questions is about the Legal Next of Kin/Informant.

Name:

Relationship:

Best Contact Number:

Email Address:

Full address of Legal Residence:

Mailing address if different:

 

 

 

Would you like to receive a confirmation email or phone call? Yes No

If yes, please enter your email or phone number:

 

 

 

 

 

 

 

 

 

 

 

 

52 Weeks of Support

It's hard to know what to say when someone experiences loss. Our free weekly newsletter provides insights, quotes and messages on how to help during the first year.