Name: Scott County Cremation
Price range: $$$$

This information is required by the State and County for the filing of the Death Certificate and to obtain the Cremation Permit.

Contact Person / Informant
Name*
First Last
Address*
Street Address City State ZIP Code
Main Phone Number of Contact Person*
Secondary Phone
Email- Of Contact Person
Contact Person's Relation to Deceased*
Deceased Person Information
Deceased's Name*
First Middle Last
Please Upload a Photo of Deceased for Identification
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 300 MB.
Sex
Deceased's Home Address
Street Address City State ZIP Code
Is deceased's address within the city limits?
- Yes
- No
Date of Death
DD slash MM slash YYYY
Time of Death

: Hours

Minutes

AM/PM
Name of Place of Death*

Residence, Hospital Name, Care Center Name
Address of Place of Death
Street Address City State ZIP Code
Doctor's Name

We need this to complete the death certificate and also to get cremation authorization.
Clinic Name and Phone Number
Date of Birth of Deceased
DD dash MM dash YYYY
Birthplace of Deceased: City, State, Country
Father's Name
First Middle Last
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Mother's Name
First Middle Last
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Mother's Maiden (last) Name

Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Deceased's Race

American Indian, White, Black ect. (if Asian, give nationality, ie Chinese, Filipino, Asian Indian, ect) (enter all that apply)
Hispanic Origin
- Yes
- No
Deceased's Social Security Number
Deceased's Usual Occupation

Please use the Job that best describes most of the decedents working days. Example: (Homemaker, Farmer, Teacher, Etc.)
Kind of Business/Industry

Example: (Agriculture, Education, Retail, Manufacturing Etc.)
Was the Deceased ever in the Armed Forces
Marital Status
Name of Spouse (first, last & maiden name, if wife)
Instructions for Cremated Remains
Next of Kin - Name
Level of Next of Kin
Please Choose
All Other Persons included in the Next of Kin
We need to know all persons that will need to sign the cremation authorization form. Example: If the decedent is married on the Spouse will need to sign, but if there is no spouse but three adult children we will need all their names so they can sign. (Name One, Name Two, Name Three)
Who is authorized to receive the Cremated Remains ?
Instructions for Release of Cremated Remains
- Pick up at Scott County Cremation
- Mail To:
Phone
This field is for validation purposes and should be left unchanged.

Online Arrangement Form

Contact Person / Informant

Deceased Person Information

Instructions for Cremated Remains

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Scott County, MN and Area Weather

Contact Person / Informant

Deceased Person Information

Instructions for Cremated Remains

Our Guarantee

Scott County, MN and Area Weather

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