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SouthCare Cremation Society

Secure Online Registration

Authorization

I, the undersigned, hereby request registration with SouthCare Cremation Society and instruct the organization, its officers and employees to have my body transported after my death has been medically established and to cause my body to be cremated and my cremated remains to be returned as instructed below:

*Indicates a required field.

My Information

 

How did you hear about us
First Name*
Middle Name
Maiden Name
Last Name*
Address*
City*
State*
Zip Code*
Inside City Limits? Yes    No
County
Phone Number*
Email Address 
Last Employer
Occupation (Most of life)
Social Security #
Highest Level of Education
 

Vital Statistics

 

Origin of Descent
Sex Male Female  
Race 
Date of Birth 
State of Birth
City of Birth
Citizen of the USA Yes    No
If not, which country?
Marital Status
Spouse's Full Name
Spouse's Maiden Name
My Father's Full Name
My Mother's Full Name
My Mother's Maiden
     

Veteran Information

A copy of the DD214 is needed to obtain
Military Honors and the US Flag.

 

Next of Kin

Georgia Healthcare Directive
Branch of Service   Full Name
Serial Number   Address
Date of Entry   City 
Location of Entry   State
Date of Discharge    Zip 
Discharge Location   Phone Number 
Last Rank     Email Address  
Last Position    Relationship
         

My Cremation Service Selection

Please indicate your Personalized Cremation Selection below.  Otherwise, please view our Personalized Cremation Packages and make your selection.

 

Simply Dignified™ Cremation - package selected:
Simply Dignified™ Cremation - full funeral service
Simply Dignified™ Cremation - viewing
Simply Dignified™ Cremation - memorial service
Simply Dignified™ Cremation - no services
         
Service / Burial / Scattering Location
   Music Selections
Readings/Poems
   Other / Newspapers for the obituary

My Wishes

In addition to the cremation package selected above, I wish to communicate the following wishes:

 

I am an eye, tissue or organ donor   I want my cremated remains buried
I want a cremation casket I want my cremated remains interred above-ground
I want an obituary I want my cremated remains scattered
         

Payment Information
Protected Lifetime Membership is $25.00 per person or $15.00 each if one or more person is registering at the same time.  Each person must register separately.  Hospice patients and Hospice Employees are free.

If you would like to Pre-pay for your Cremation Service Selections, please select the box labeled, Lock-in my "selected" costs.
Card Type*

 

$25.00

I am also registering with:
Name*   $15.00 
Card Number*   Hospice Patients / Employees
(No Charge - Free Membership for Hospice)
Expiration Date*      
V-Code*      

VISA/MC: A three digit code located on the back of the card.
AMEX:The four digit number is located on the front of the card.

Lock-in my "selected" costs: I want to prepay and lock-in the cost for my services, please have someone contact me.
 

I, affirm that all of the information was completed by the registrant or owner of the credit card and authorize SouthCare to charge my credit card for the amount indicated in the Payment Information section of this form. To receive member pricing, you need to be registered as a member for at least 24 hours prior to passing.

 

        

 

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