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General Assistance Cremation Application

  1. Deceased Information
  2. Yes or No
  3. Household Income/Assets/Resources
  4. Was the death related to COVID-19?
  5. Agreement Statement
    I declare that I have provided the information indicated and, to the best of my knowledge, it is true, accurate, and complete. I agree to provide verification(s) if requested, to determine the deceased's financial eligibility. I further agree to cooperate with the funeral home in securing any and all income/assets/resources of the deceased.
  6. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  7. Leave This Blank:

  8. This field is not part of the form submission.