Generating & sending work order…
Moon City Mortuary Service LLC
Cremation Pickup Queue
Submit for cremation pickup.
1
Decedent Information
Full Legal Name of Decedent
*
Full legal name is required.
Date of Birth
*
Date of birth is required.
Date of Death
*
Date of death is required.
SSN
*
Valid SSN is required (XXX-XX-XXXX).
Address of Pickup or Funeral Home for Pickup
*
Pickup address is required.
2
Special Instructions & Safety
Special Notes / Requests
(optional)
Does the decedent have a pacemaker or any battery-operated implant?
*
Yes
No
Please select Yes or No.
If Yes, describe device type and location on body
*
Device description is required when pacemaker/implant is present.
Optional Attachments
Medical Authorization
Attach File
×
Not attached
Next of Kin Authorization
Attach File
×
Not attached
Do not write below this line — This section is for Moon City Mortuary personnel only.
This section will appear on the printed form for MCM personnel to complete.
3
Moon City Mortuary — Contractor Use Only
Cremation ID #/Name
Date of Cremation
Time of Cremation
Performed By
Contractor Signature
Cremation ID #/Name
Date of Cremation
Time of Cremation
Performed By
Contractor Signature
Submit & Print
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