Make Arrangements

REQUEST FOR ENDSWELL’S SERVICES

If you are interested in making arrangements with Endswell for Aquamation, Cremation, or Green Burial, please complete this form or call us at 919.907.9777.

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Planning

Who are these arrangements for? *

For Myself
For Someone Else

When are these arrangements for? *

Pre-Arrangement for Future
I Need Services Now
I Need Services Soon

Would you like to provide your basic contact information or complete our full Intake Form? *

Basic Contact Information
Full Intake Form

Who referred you to Endswell?

Future Planning for Yourself

Name *

First

Last

Date of Birth *

Email *

Phone *

Preferred Contact *

Preferred Doc Delivery *

Address

Address Line 1

City

State

Zip Code

Information for Your Loved One

Name *

First

Last

Gender *

Male
Female

Date of Birth *

Primary Contact For Follow Up

Preferred Doc Delivery *

Preferred Contact *

Relationship to Loved One *

Other

Name *

First

Last

Phone *

Email *

Address

Address Line 1

City

State

Zip Code

Message

Please specify if you are interested in Aquamation, Cremation, or Green Burial and provide any relevant Notes / Requests / Questions

Contact Details

Email of Individual Completing Form *

If you are filling out this form for someone else, please provide your name, email, phone number, and address, as well as your relationship to the individual for whom these arrangements are being made. *

First

Last

Phone Number of Individual Completing Form *

Address of Individual Completing Form *

Address Line 1

Address Line 2

City

State

Zip Code

Relationship to the individual for whom the funeral service is being arranged. *

Full Legal Name - This is the full legal name of the individual for whom the funeral service is being arranged. *

First

Middle

Last

Are there any aliases? *

Please provide the legal residence. *

Address Line 1

City

State

Zip Code

In what County is the legal residence located? *

Is the legal residence inside the city limits? *

Please Enter Date of Birth *

Personal Details

County of Birth? *

State of Birth? *

Gender? *

Race? *

Current Marital Status *

Married
Divorced
Never Married
Widowed
Separated

Last name prior to first marriage *

Please provide spouse's current full legal name. *

First

Middle

Last

Please provide spouse's full name prior to first marriage. *

First

Middle

Last

Father's full name prior to first marriage *

First

Middle

Last

Mother's full name prior to first marriage. *

First

Middle

Last

Military Service? *

Which Military Service *

Highest Level of Education Completed *

8th Grade or less
9th-12 grade, no diploma
High School graduate or GED completed
Some college credit by no degree
Associate degree (e.g. AA, AS)
Bachelor's degree (e.g. BA, AB, BS)
Master's Degree (e.g. MA, MS, Meng, Med, MSW, MBA)
Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)
Unknown

Occupation *

Example: Teacher - This should NOT say retired. Please list the role that the individual spent the majority of their career performing.

Industry *

Example: Education - This should NOT say retired. Please list the industry that the individual worked in for the the majority of their career.

Next of kin (N.O.K.) name, relationship, phone number, and email address

The next of kin will authorize Endswell to proceed with the aquamation, cremation, or green burial service. If married, please provide contact information for spouse. If divorced, separated, or never married, please provide contact information for children, if any. If there are multiple children, please provide their names and contact information. If there are no children, please provide information for siblings or parents.

How many Next of Kin would you like to include? *

Next of Kin 1 Name *

First

Last

Next of Kin 1 Relationship *

Next of Kin 1 Email *

Next of Kin 1 Phone Number *

Next of Kin 2 Name *

First

Last

Next of Kin 2 Relationship *

Next of Kin 2 Email *

Next of Kin 2 Phone Number *

Next of Kin 3 Name *

First

Last

Next of Kin 3 Relationship *

Next of Kin 3 Email *

Next of Kin 3 Phone Number *

Next of Kin 4 Name *

First

Last

Next of Kin 4 Relationship *

Next of Kin 4 Email *

Next of Kin 4 Phone Number *

Next of Kin 5 Name *

First

Last

Next of Kin 5 Relationship *

Next of Kin 5 Email *

Next of Kin 5 Phone Number *

Next of Kin 6 Name *

First

Last

Next of Kin 6 Relationship *

Next of Kin 6 Email *

Next of Kin 6 Phone Number *

Next of Kin 7 Name *

First

Last

Next of Kin 7 Relationship *

Next of Kin 7 Email *

Next of Kin 7 Phone Number *

Next of Kin 8 Name *

First

Last

Next of Kin 8 Relationship *

Next of Kin 8 Email *

Next of Kin 8 Phone Number *

Other Details

If there are any special spiritual or religious requests or if you or the family would like to arrange a viewing (visitation) of the body, please note them here.

How many death certificates would you like us to order? *

Endswell includes 3 Death Certificates in our packages for no additional charge. Please enter the total number you would like to receive here.

Please select your funeral service *

Aquamation
Cremation
Green Burial
Human Composting
Undecided

Would you like to arrange a funeral service, visitation, or memorial service?

Do you want to pickup the urn at Endswell or have the urn delivered? *

Pickup at Endswell
Have the urn delivered

For aquamation and cremation services, to whom should we deliver the urn?

First

Last

To where should we deliver the urn? *

Address Line 1

Address Line 2

City

State

Zip Code

If you have a cemetery plot, what is the name of the cemetery?

Special Requests

Please let us know if you have any special requests. *

Lock of hair
Fingerprint Scan (to be used for Jewelry)
None
Other

Other

Imminent Need

The following questions are necessary when there is a need for services in the immediate future (within the next month).

Is there an imminent need for services from Endswell? *

If you need our services now or anticipate the need for our services within the next month, please select YES.

Has death occured? *

If death has occurred, please enter date of death.

If death has occurred, what is the address at that location?

Address Line 1

Address Line 2

City

State

Zip Code

If death has occurred, what County did it occur in?

Are you working with Hospice?

Hospice Agency

Name of hospice contact

First

Last

Phone number of hospice contact

Are you working with a primary health care provider?

Name of Primary Care Office

Name of doctor or nurse practitioner

First

Last

Phone Number of doctor or nurse practitioner

Please provide the Social Security Number.

Ready to get started or want to learn more?

Endswell

Our Team

Testimonials

News and Events

Service Areas

Chapel Hill North Carolina

Raleigh North Carolina

Cary North Carolina

Durham North Carolina

Greensboro North Carolina

Hillsborough North Carolina

What is Aquamation

Aquamation Cost

Arrange Aquamation Service

What is Cremation

Cremation Cost

Arrange Cremation Service

What is Green Burial

Green Burial Cost

Green Burial Grounds

Arrange Green Burial Service

Planning Resources

Make Arrangements

Bluestem Conservation Cemetery

General Price List

Grief Resources

Make Arrangements

REQUEST FOR ENDSWELL’S SERVICES

Planning

Future Planning for Yourself

Information for Your Loved One

Primary Contact For Follow Up

Message

Contact Details

Personal Details

Next of kin (N.O.K.) name, relationship, phone number, and email address

Other Details

Special Requests

Imminent Need

Ready to get started or want to learn more?