Valley Memorial

Service Authorization Form

Please complete all fields below. Our team will review your submission and contact you within a few hours to confirm arrangements.

Required fields are marked with *

Information about your loved one

Full name of deceased *

Date of birth *

Date of passing *

Gender

Place of passing (hospital, residence, etc.)

City

State

ZIP code

Your contact information

Your full name *

Relationship to deceased *

Phone number *

Email address *

Your address

Service requested

Service requested *

Additional notes or special requests

Authorization

By typing your full name below, you authorize Valley Memorial to receive and care for the remains of your loved one and proceed with the requested services.

Type your full name as signature *

Today's date *

Your information is kept strictly confidential.

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