Book Now – End of Life Ceremony

My heartfelt condolences for your loss.

The form below is for those who would like to use it to start our conversation, but you can also simply call me at 407-608-9242.

This form does not confirm services; a signed service agreement is needed to confirm the date and service requested.

In the below, you can fill out only the required information (just your contact information), or you can use the questions to begin exploring details that are important in the service, eulogy, and/or obituary. When we meet, we’ll discuss these and how to incorporate this into the service.

I’m a call or text away if you have questions, 407-608-9242.

REQUESTOR INFORMATION

Name *

First

Last

Preferred Pronouns

Email *

Phone *

Mailing Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Your relationship to the deceased

Celebrant Services Requested (please mark all that apply) *

• Humanist support / presence in communicating with funeral home, cemetery, and other professionals
• Invocation/Reading Only (deliver Humanist Invocation or reading at a religious or other funeral ceremony)
• Write Eulogy / Obituary
• Officiate funeral, memorial, or celebration of life
• Deliver Eulogy during Service
• Be present for viewing / visitation
• Deliver Humanist Invocation at graveside service / committal
• Attend or visit reception / repast

SERVICE INFORMATION

Name of funeral home caring for your loved one

Funeral home number (for people to call for information about the service)

Date and Time of Service (first service time if there are multiple services)

Date

Time

Date, Time, and Location of funeral, memorial, or celebration of life

Date, Time, and Location of viewing / visitation

Date, Time, and Location of graveside service / committal

Date, Time, and Location of reception / repast

INFORMATION FOR SERVICE, EULOGY, and/or OBITUARY

Name *

First

Middle

Last

Preferred Pronouns

Nicknames or preferred name usage

Age at time of death

Date and place of birth

Date and place of death

Cause of Death if you would like that included in the Eulogy or Obituary

For example, some will include “after a heroic battle with breast cancer…” and follow at the end with request for donations to a breast cancer research fund.

Origins - where family from / heritage

Mother's name

First

Last

Include maiden name if you’d like it included. E.g., Jane Smith (maiden: Fredricks)

Mother isLivingDeceased

Father's Name

First

Last

Father isLivingDeceased

Decedent is survived by (list surviving siblings, children, grandchildren, grandparents, friends, pets, etc.):

For multiple people (such as three siblings), include year of birth or list in order of oldest first. Spouses of children are listed with first name in parentheses. (e.g., Son, James Smith (Wilma), …)

Decedent joins in peace (list pre-deceased siblings, children, grandchildren, grandparents, friends, pets, etc.):

Marriage / marriages to recognize. If you'd like, include their love story (how met, when/where married, significant moments together, or other information about their life together)

Military Service (branch, years, rank, memberships, other important information)

Please include if military honors will part of the funeral service.

Education - school(s), college(s), etc., fields of study, other significant information.

Awards, Honors, Recognition

What did your loved one enjoy? (hobbies, passions, sports, activities, etc.)

Profession / Occupation (industry, job title, activities, stories, colleagues, etc.)

The "other job" – whether volunteer work, helping neighbors, or a hobby that was like a piece of their soul, were their vocations in addition to their profession / occupation?

Community Involvement & Memberships: charitable organizations, RSSI (Religious, Secular, or Spiritual Identity) organizations, political, fraternal, or other affiliations

What made your loved one unique?

It’s the little things – the quirky smile, the catchphrase, the quick wit, the way they couldn’t resist singing with 80’s rock songs on the radio.

What were they most proud of (most important accomplishments, the difference they made in the world)

Words of wisdom - a quote or life lesson: What would they want their loved ones to know?

Did they have a personal mission statement, dearly held values, or other internal guideposts or beacons?

Three best words to describe your loved one

Quote or short poem that they loved

Buzzwords (words they used all the time, that we can incorporate into the service to personalize it)

Wording for charitable donation request

For example, “In honor of Bill’s military service, the family requests your support for the Wounded Warrior Project in lieu of flowers”

Link to memorial fund (URL):

Anything else you'd like to add

Gratitude to express to people, groups, or organizations / institutions

e.g., the family is ever grateful to the staff at Vitas Hospice for their loving care and support over the past six weeks...

Spam Test *

What color am i thinking of?

Rhymes with fellow

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