Online At-Need Form :: Lupinski Funeral Home, Inc.

Please note that by completing and submitting or faxing the On Line At Need Form to Lupinski Funeral Home, Inc. that this is NOT considered notification that a death has occurred. Please call the funeral home at 203-865-4205 to speak with a funeral director.

Thanks for taking the time to fill out our Immediate Need Form. By completing the following information 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 provided on this form will help Lupinski Funeral Home, Inc. complete the death certificate and other required documents. In addition, this information will assist the funeral director to better understand your initial wishes. Relaying required statistical information can be time consuming. Our desire is to help expedite the final arrangement conference at the funeral home and make the process a little more comfortable.

Please complete (as much as possible) the information on the form and select Submit Information at the end to send the information to us. You may also print out the form and bring it with you to the arrangement conference or fax.

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 whatsoever, please contact Lupinski Funeral Home, Inc. at: 203-865-4205

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.

Deceased Vital Statistics for Death Certificate

* First Name :

* Last Name :

Middle Name :

Sex :

Race :

Date of Birth :

Place of Birth :

Date of Death :

City of Death :

State of Death :

County of Death :

Location of Death :

If other, please indicate address:

Name of the Place of Death :

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 :

Length of Residence In County :

Father's Full Name :

Mother's Maiden Name :

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

Preparation and Viewing
Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming. Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only. If you elect NOT to order embalming, State law requires refrigeration of an unembalmed body that is held for over 24 hours from the time of death.
The Family Preference Regarding Viewing/Embalming Is
I Authorize Lupinski Funeral Home, Inc. To Embalm
Name of Authorizing Person :
Relationship To Deceased :

Veteran Information
Was Decedent 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 :
* E-Mail :
Address :
City :
State :
Zip Code :
Telephone Number :

Funeral/Memorial Service Information:
Preferred Place of Service
Religious Denomination :
Is there Immediate 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:

Immediate Need Form - Printer-friendly Version

You can download the printer-friendly version of the Immediate Need Form to your local computer from the link below. Once downloaded, open the PDF *, and enter your information on the form, then print it out on your printer. You may then fax it to us at the fax number 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.)

* 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.

Completed forms may be faxed to the number below::

Fax: 203-865-0278

Please call with any questions: 203-865-4205

Online At-Need Form

Deceased Vital Statistics for Death Certificate

Type of Disposition

Preparation and Viewing

Veteran Information

Informant/Person In Charge Information

Funeral/Memorial Service Information:

Other Information & Instructions

Immediate Need Form - Printer-friendly Version