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NASSAU SUFFOLK
CREMATORY
132 Ronkonkoma Avenue
Lake Ronkonkoma, NY 11779
(631) 467-2900
©1999 MKJ Marketing
Whether or not you choose a cremation package today, we encourage you to complete this preplanning form. All information will be held in strict confidence. We will keep it on file at our crematory and provide you with a printed copy. If you would prefer to speak with one of our prearrangement counselors in person, simply call and make an appointment. We can meet with you at our crematory or in your home.
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Name (First, Middle Initial, Last)
Address
City
State Zip
Phone (Please include area code)
Sex Color Marital Status
Simple Cremation for $354
If you select this option, your credit card will be charged a total of $354 for the simple cremation service. If you choose not to enter your credit card information at this time, please complete the remainder of the preplanning form. We will contact you to arrange a method of payment that is most convenient

Name (As printed on card)
Type of card Exp. Date
Credit Card Number
Personal Information
Age
 Social Security Number
Age of spouse if alive
 Citizen of what country
Date of birth
 Birthplace (City & State)
Occupation
 Place of business
Education
Father’s name
 Father’s birthplace
Mother’s maiden name Mother’s birthplace
Benefit Information
Military Service
 Branch
Date of enlistment
 Service number
Date of discharge
Funeral or Memorial Service Preferences
Type
Funeral home
Address
City
State
 Zip
Phone (Please include area code)
Clergy
Music, readings, etc.

Pallbearers

Honorary pallbearers

Special requests

Clothing, jewelry, etc.

Casket/urn

Burial vault

Flowers

Preferences for Final Disposition Family Burial Property
Location

Number of spaces
Which space

Other: (Scattering, Mausoleum entombment, etc.)

Preferences for Memorialization