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Vital Statistics Information Form

(Cremation Death Certificate)

Type NA for None
( If Advance Planning Leave Blank)
( If Advance Planning Leave Blank)
( U= Unknown )
( U= Unknown )
( U= Unknown )
( Answer Only If Not United States )

( U= Unknown) ( D= Disabled)
( U= Unknown) (N= None)
( U= Unknown) (N= None)
First, Middle Name or Middle Initial, Last ( If Wife, Give Maiden Name) ( N=None)
First, Middle Name or Middle Initial, Last ( N=None)
First, Middle Name or Middle Initial, Last Name should be Maiden Name ( N=None)

Contact information for person completing this form

Please contact us at 404-963-5634 after completing this form to schedule arrangements.

CERTIFICATION AND INDEMNIFICATION

THE AUTHORIZING AGENT ACKNOWLEDGES THAT WILLIAM GAYLEANO MURRAY & SON FUNERAL HOME, INC. IS RELYING UPON THE REPRESENTATIONS BEING MADE BY THE AUTHORIZING AGENT IN THIS AUTHORIZATION. THE AUTHORIZINGAGENT CERTIFIES THAT ALL OF THE INFORMATION AND STATEMENTS CONTAINED IN THE AUTHORIZATION ARE ACCURATE AND NO OMISSIONS OF ANY MATERIAL FACT HAVE BEEN MADE. THE AUTHORIZING AGENT AGREES TO INDEMNIFY AND HOLD HARMLESS WILLIAM GAYLEANO MURRAY & son funeral home, inc., THEIR OFFICERS, DIRECTORS, EMPLOYEES AND AGENTS FROM ANY AND ALL CLAIMS, DEMANDS, ACTIONS, CAUSES OF ACTION OR SUITS OF ANY KIND OR NATURE WHATSOEVER, INCLUDING, BUT NOT LIMITED TO, LEGAL FEES ARISING OUT OF OR RESULTING FROM WILLIAM GAYLEANO MURRAY & SON FUNERAL HOME, INC. RELIANCE ON OR PERFORMANCE CONSISTENT WITH THE DIRECTIONS, STATEMENTS, REPRESENTATIVES, AND AGREEMENTS CONTAINED IN THIS AUTHORIZATION AND CREMATION PROCESS DISCLOSURE.

ALL FORMS MUST BE COMPLETED, SIGNED, AND RETURNED TO WILLIAM GAYLEANO MURRAY &SON FUNERAL HOME, INC. IN ORDER FOR CREMATION TO TAKE PLACE. WE’VE MADE THESE FORMS AVAILABLE ONLINE/ BY EMAIL, SO YOU CAN COMPLETE THEM AT YOUR CONVENIENCE IN THE COMFORT OF YOUR OWN HOME. IF YOU HAVE QUESTIONS REGARDING ANY OF THE FORMS ON THIS PAGE, PLEASE CALL OR CONTACT US.

 IF THE FAMILYIS UNABLE TO PROVIDE THESE ITEMS, AND CREMATION IS DELAYED BEYOND 48 HOURS, SUCH FAILURE WILL RESULT IN A SHELTERING REMAINS CHARGE OF $75.00 PER DAY.

BY SUBMITTING THIS FORM I AFFIRM I HAVE READ, AGREE TO AND ACCEPT THE TERMS, CONDITIONS, DISCLOSURES, AUTHORIZATIONS AND ACKNOWLEDGEMENTS PRESENTED ABOVE.

Cities Served for $1,275.00 Simply Cremate Package: Cities listed in distance closest to farthest from William Gayleano Murray & Son Funeral Home, Inc. Lithonia, Redan, Stone Mountain, Snellville, Conyers, Decatur, Pine Lake, Lilburn, Clarkston, Avondale Estates, Scottdale, Tucker, Ellenwood, Atlanta, Norcross, Lawrenceville, Grayson, Loganville, Oxford, Stockbridge, Conley, Rex, Porterdale, Duluth, Morrow, Peachtree Corners, Covington, North Metro, Forest Park, Jersey, Mcdonough, Jonesboro, Dacula, Alpharetta, Riverdale, Suwanee, Bethlehem, Roswell, Monroe, SocialCircle, Lovejoy, Red Oak, Auburn, Smyrna, Marietta, Buford, Hampton, Mansfield, Mableton, Locust Grove, Union City, Austell, Fayetteville, Winder, Jenkinsburg, Sunny Side, Canton, Rutledge, Good Hope, Jackson, Hoschton, Fairburn, FloweryBranch, Lithia Springs, Newborn, Cumming, Braselton, Clarkdale, Griffin, Woodstock, Statham, Chestnut Mountain, Tyrone, Bostwick, High Shoals, Experiment, ShadyDale, Kennesaw, Bogart, Bishop, Powder Springs, Oakwood, Flovilla, PeachtreeCity, Lebanon, Douglasville, Holly Springs, Palmetto, Talmo, Watkinsville, Farmington, Gainesville, Jefferson, Monticello, Orchard Hill, Madison, Brooks, Pendergrass,Sharpsburg, Hiram, Acworth, Athens, Newnan, Turin, Milner, Senoia, Winston, BallGround, Williamson, Haralson, Dallas, Buckhead, Gillsville, Nicholson, Zebulon

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