Holy Cross Catholic Church

Las Cruces, NM

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Intake Form

- Details about deceased - to be completed by family
  
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  Name of Deceased (Legal first and last) REQUIRED Please fill out this field. Please enter valid data.
  
  Date of birth: REQUIRED Please fill out this field. Please enter valid data.
  
  Date of death: REQUIRED Please fill out this field. Please enter valid data.
  
  Last Address of Residence (street, city, state and zip) REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Next of Kin: REQUIRED Please fill out this field. Please enter valid data.
  
  Next of Kin Relationship to Deceased: REQUIRED Please fill out this field. Please enter valid data.
  
  Contact Name: REQUIRED Please fill out this field. Please enter valid data.
  
  Other Surviving Family Members (name and relationship): Please enter valid data.
  
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