Internship Funeral Arrangement Case Report Form - Minnesota Department Of Health Page 2
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2Finalize Funeral Arrangements
Contact drivers for funeral vehicle(s):
____
Arranged for at-need or pre-need services
_____
___
Limousine
(circle one)
___
Hearse
____
Discuss and confirm selection of services
___
Floral car
___
Traditional service with burial
___
Lead car
___
Traditional service with cremation
___
Commemorative vehicle
___
Immediate burial
Specify vehicle:__________________________
___
Direct cremation with memorial service
____
Arrange for luncheon
___
Direct cremation without service
-Location:______________________________
___
Forwarding of remains to another FH
-Name of caterer:________________________
___
Receiving remains from another FH
____
Contact Fort Snelling National Scheduling
___
Shipment of remains
Office:
___
Trade call or
- Case number:___________________________
List other:______________________________
-Assembly area:__________________________
____
Request and recommend clothing & accessories
____
Discuss service information
____
Itemize statement of funeral goods & services
-Religious denomination:__________________
____
Summarize statement of funeral goods &
-Location of visitation:____________________
services with NOK
-Location of funeral service:________________
____
Review GPL with NOK
-Witnessing of cremation:__________________
____
Obtain NOK signature(s) on statement of funeral
____
Specify type of facility hosting visitation or
goods & services
service:
____
Discuss payment policy
___
Church
-Total balance of statement:________________
___
Community Center
-Balance collected at arrangements:__________
___
Cemetery
-Balance paid in full or scheduled payment
___
Funeral Home
arrangements (circle one)
___
Decedent’s Residence
____
Accept method of payment for services:
List other:______________________________
___
Cash
___
Credit Card
____
Contact clergy to facilitate funeral
___
Check
____
Contact the musician
___
Money Order
___
Harpist
___
Insurance
___
Organist
___
Pre-Need Account
___
Pianist
___
Crime Victim Reparation Board
___
Violinist
___
County Burial Assistance or
___
Cantar
List other:______________________________
___
Soloist
___
Choir or
____
Present NOK with copies of finalized statement
List other:______________________________
of funeral goods and services and receipt of
payment
____
Contact Casket bearers
____
Contact Embassy for HR shipment requirements
Intern license #:________________________________
-Name of country:________________________
____
Contact MDH for Letter of Non-Contagion
Name of Intern:_________________________________
____
Contact funeral support staff
-Number of staff requested:_________________
Signature of Intern:_________________ Date:________
____
Contact cemetery for burial or entombment
____
Contact the crematory for cremation
Funeral Arrangement Case Report #(1-25):___________
(Updated 8/2015)
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