| Purchaser Information |
| Name of Purchaser: |
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| Address: |
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| City/State/Zip: |
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| Phone: |
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| E-Mail: |
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| Casket Beneficiary Information (person's name who will use the casket) |
| Name of Casket Beneficiary: |
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| Address: |
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| City/State/Zip: |
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| Beneficiary Date of Birth: |
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| Age: |
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Social Security # of Beneficiary:
(last 4 digits only) |
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| NOTE: Purchaser and Beneficiary may or may not be the same person. If you are purchasing the casket for yourself, you are both the Purchaser and Beneficiary. If you are purchasing a casket for someone else (spouse, parent, etc.), the Purchaser and Beneficiary are two different people. The Beneficiary is the person who will use the casket. |
| Funeral Home Information |
| Name of Funeral Provider: |
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| Address: |
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| City/State/Zip: |
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| Telephone: |
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| If the funeral provider is unknown, please indicate the likely shipping destination (City & State) of the casket: |
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| Casket Model |
| Please indicate casket desired: |
Premium Rectangular
Premium Shaped
Simple Shaped
Simple Rectangular |
| Wood Selection |
| Please indicate wood species: |
Walnut (Available only in Premium Caskets)
Oak (Available in Premium & Simple Caskets)
Pine (Available only in Simple Caskets) |
| Cross Preference |
| Please indicate cross preference: |
Select With Cross on Lid
Select Without Cross on Lid |
| How did you first learn about us? |
| Please tell us how you first learned about Trappist Caskets: |
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