Time of Need Form

By completing the following form at your own convenience, you should find it easier to provide correct information and have some time to think about the type of services you desire. The information will help expedite the final arrangement conference at the funeral home and make the process a little more comfortable for you.

Please enter as much of the information on the form as possible. When complete, you may:

  • Select Submit Information at the end to transmit to us
     
    OR
  • Print out the form and bring it with you to the arrangement conference or fax it to us at (804) 355-8700.

If you'd prefer, a printer-friendly version of this form is also available for you to download and fill out manually. CLICK HERE for further instructions and the download link, if interested.

If you have any questions, please contact Bliley's at (804) 355-3800. We will be glad to assist you.
NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

 Vital Statistics for Death Certificate
* First Name:
* Last Name:
Middle Name:
Sex:
Race:
Date of Birth:
Place of Birth: City:

State:

Country:
Date of Death:
City of Death:
State of Death:
County of Death:
Place of Death:
If other, please indicate address:
Social Security Numer:
Education
Usual Occupation (most of life):
Kind of Business:
Company:
Marital Status:
Full Name of Surviving Spouse:
If Wife, Provide Maiden Name:
Residence - Street Address:
City/Town:
Inside City Limits:
County:
State:
Zip Code:
Father's Full Name:
Mother's Full Maiden Name:

 Type of Disposition
Disposition Will Be:
If Cremation, Indicate Preference For Cremated Remains:
Name of Cemetery (if applicable):
City:
State:

 Preparation and Viewing

Important Note: Viewing of the body is an option for the family. In most cases, embalming is required or recommended for public viewing/visitation. The funeral home is required to have authorization from the next of kin for embalming.
The Family Preference Regarding Viewing/Embalming Is:
I Authorize Bliley's To Embalm:
Name of Authorizing Person:
Relationship To Deceased:

 Veteran Information
Was Decendent Ever In the US Armed Forces?: Yes No (if no, continue to next section)
Branch of Service:
Date Enlisted:
Date Discharged:
Honorable Discharge: Yes No
Military Serial Number:
Is A Copy of Discharge Papers Available? Yes No (if yes, please bring for us to copy):

 Informant/Person In Charge Information
* First Name:
* Last Name:
Relationship To Deceased:
* Email Address:
Address:
City:
State:
Zip Code:
Telephone Number:

 Funeral/Memorial Ceremony Information
Preferred Place of Ceremony:
Religious Denomination:
Is there Time of Need Funeral Insurance on decedent?: Yes No
If Yes, Specify Insurance Type:
(i.e., Forethought, Purple Cross, trust, etc.)

 Other Information & Instructions
Please list any other instruction or information you would like us to have:



 Time of Need Form - Printer-friendly Version

You can download the printer-friendly version of the Time of Need Form to your local computer from the link below. Once downloaded, open the PDF *, and enter you information on the form, then print it out on your printer. You may then either mail it to us at the address below, or bring it with you when you visit.

»   CLICK HERE to download the form - choose to, 'Save to Disk,' in the dialog box that appears (download times will vary depending upon connection.)
Get Adobe Acrobat Reader* NOTE: Adobe Acrobat Reader software is required to view this file - if you don't already have the Reader installed on your computer, it is available for free from Adobe's website - please click the icon at right to be taken to the download page.

Mail completed forms to this address:

Bliley's
P.O. Box 6267
Richmond, VA 23230

Please call with any questions: (804) 355-3800


 

Bliley's
Personalized Funeral & Cremation Services
Richmond, Virginia
 
© 2008-2009 Copyright, Bliley's and FuneralNet ® 

 Central
3801 Augusta Ave.
»   » Map 		Chippenham
6900 Hull Street Rd.
»   » Map 		Staples Mill
8510 Staples Mill Rd.
»   » Map 		 Contact Us
(804) 355-3800
HOME | CONTACT US

“For more than 135 years, the Bliley family has been devoted to serving the Richmond community with compassion, honor and respect. We live these ideals in everything we do and in every service we provide.”