If a death has occurred, please contact us at 610-372-4160 to report the death before completing this form. Step 1 of 26 3% Current Situation*I want to preplan my funeral.I want to preplan a loved one's funeral.A loved one's death is imminent (within 90 days) and I want to make prearrangements.A loved one has passed and I need to make final arrangements.Signee*Is the person for whom arrangements are being made (the "Applicant") able to sign documents or will someone else be signing on their behalf? Note that in order to sign for another person, you must be the legal next of kin or assigned POA. Order of kinship is Spouse, Children, Parents (if still living), Sibling, Aunt/Uncle, Niece/Nephew, Cousin. The Applicant can sign.The legal next of kin or POA will sign on my loved one's behalf.Contact Email*Please provide an email address where forms can be sent or if we need to contact you. Phone Number*Please provide a phone number where you can be reached if we have any questions about your application.Forms*Would you prefer to receive your documents via email (you will need to print them out) or regular mail?EmailPostal MailIdentification*We require a photo of the person for whom arrangements are being made. We use this for identification purposes at the time of death. If you do not have a digital photo, you may provide us with a physical photo when you mail/drop off your signed documents to us. We will return the photo to you. If you do not have any photos, you must be present at the time the person for whom arrangements are being made is picked up from the place of death and confirm identification of decedent.I can upload a photo now.I will mail/drop off a photo.I don't have a photo and will be present when my loved one has passed.Select Photo to Upload*Accepted file types: jpg. Save and Continue Later Preparer InformationThis section relates to the person who is providing the information and signing documents.Preparer Relationship*What is your relationship to the person for whom you are making these arrangements? If you are a direct relative and also POA, select your family relationship not POA.SpouseDaughterSonSisterBrotherMotherFatherAuntUncleNieceNephewCousinPOAStep DaughterStep SonStep BrotherStep SisterStep MotherStep FatherGrandparentIn LawCompanionFriendAttorneyExecutorCase WorkerPreparer's Name* First Middle Initial Last Preparer's Address* Street Address City State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY Zip Preparer's Social Security Number*If unknown, enter 999-99-9999. Preparer's Date of Birth* Save and Continue Later Informant InformationPlease provide us with a secondary contact person. This is generally a family member who will most likely report your death to us, such as a spouse, child, or sibling. It could also be your POA or executor. Informant Relationship*What is the Informant's relationship to the person for whom you are making these arrangements?SpouseDaughterSonSisterBrotherMotherFatherAuntUncleNieceNephewCousinPOAStep DaughterStep SonStep BrotherStep SisterStep MotherStep FatherGrandparentIn LawCompanionFriendExecutorAttorneyCase WorkerInformant Name* First Middle Last Informant Address* Street Address City State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY Zip Informant Phone*Informant Email(optional) Save and Continue Later Cremation PackageMillennial CremationThis package includes pick up of body within Berks County from the place of death during normal business hours (M-F 7am-7pm), transportation of body to the funeral home, holding of body in refrigeration up to 3 days while permits and certificates are completed, data entry of all biographical information, completion of the death certificate, submission of notice to social security, completion and submission of Veteran notice of death to Berks Veteran Association (if applicable), arrangement of Military honors (if applicable), submission of request for Coroner’s cremation permit, delivery of documents to crematory, transportation of body to the crematory, transportation for retrieval of cremains from the crematory to the funeral home, crematory fee, and Berks County Coroner’s permit fee. Cremains are returned in a cardboard box. Price: $975.00 Millennial Cremation At NeedThis package includes pick up of body within Berks County from the place of death during normal business hours (M-F 7am-7pm), transportation of body to the funeral home, holding of body in refrigeration up to 3 days while permits and certificates are completed, meeting at funeral home to sign papers, data entry of all biographical information, completion of the death certificate, submission of notice to social security, completion and submission of Veteran notice of death to Berks Veteran Association (if applicable), arrangement of Military honors (if applicable), submission of request for Coroner’s cremation permit, delivery of documents to crematory, transportation of body to the crematory, transportation for retrieval of cremains from the crematory to the funeral home, crematory fee, and Berks County Coroner’s permit fee. Cremains are returned in a cardboard box. Price: $1,475.00 Extended Removal TimeOur standard package includes removal of the deceased during normal business hours (M-F 7am-7pm). If you would like to ensure removal occurs at any time of day including weekends, please select Extended Pick Up. For Preplans: If at the time of death the removal can be made during normal business hours (M-F 7am-7pm), this amount will be refunded if prepaid. Similarly if not selected, this charge will added to the final bill.Extended Pick Up: $295Regular Pick Up (included)Location*Is the person for whom these arrangements are being made currently located in Berks County?YesNoAdditional TransportationFor deaths occurring outside of Berks County (limited to 50 miles), additional transportation costs are required. Price: $250.00 Save and Continue Later Package OptionsMeet with the Funeral DirectorWhile the Millennial Service is generally completely totally electronically, if the family prefers to meet with the funeral director at the funeral home or at their residence, this is the added cost for the director’s time, funeral home use/travel time. (up to 3 hours) Meet with Director: $895No Meeting (included)Private Family ViewingIf the family would like to see the deceased prior to cremation, a private viewing can be scheduled. This viewing is for immediate family ONLY (spouse, children, siblings, parents) at the funeral home within 24 hours of death. It includes dressing if desired, posing of features, and sanitation. There is no embalming, or cosmetizing.Private Family Viewing: $695No Family Viewing (included) Save and Continue Later Package Options: Death CertificatesDeath CertificatesMost people require death certificates to settle any estate assets for which the deceased's name is listed either solely or jointly. These include Bank Accounts, Pensions, Insurance Policies, 401Ks and other financial accounts; physical assets such as houses and vehicles; and to claim any eligible Social Security Benefits for spouses and dependent children. We recommend ordering at least 5. We can order additional death certificates from the local registrar up to 90 days after death with same day or next day turnaround time. After 90 days requests have to be made through PA Vital Records at an added retrieval cost of $29 in additional to the cost for the death certificate. Turn around time varies from four weeks to several months. Eligible Veterans are entitled to 10 free death certificates; however, these are not immediately available and must be ordered, which we will do for you. Turnaround time is 4-6 weeks. Please note: Cost of death certificates is not inflation proof as we do not control the price. Additional cost, if any, will be added to the final bill. Price shown below is per copy. Price: $20.00 Quantity: Save and Continue Later Package Options: ServicePackage Add OnsPopular AdditionsSelect options to add to your package. Memorial Service Clergy Register Book Prayer Cards Memorial Service: If you would like to celebrate your loved one with a Memorial Service after the cremation at our funeral home, this option includes a two-hour memorial service. Priest/Reverend (Clergy): We can arrange for a priest/reverend of the denomination of your choice to conduct a prayer service at the memorial. Some clergy may charge a higher fee for their services at the funeral home. If applicable, this will be added to your final cost. Note: If prepaid, this item is not inflation proof. Register Book: We can provide a register book for your guests to sign whether your memorial service is at our funeral home or at another location. Prayer Cards: We can create prayer cards for you as keepsakes for your family. Each set includes 8 laminated cards and 25 Thank You/Acknowledgement cards. We have a selection of cards and prayers to choose from or we can create a custom card for you. Save and Continue Later Package Options: ObituaryArranging Local Obituary Service: $75While not legally required, many families choose to have an obituary prepared for their loved one. This is our fee to prepare the obituary for submission to the newspaper. This fee applies regardless of whether we compose the obituary for you or you provide us with an obituary. It covers our time to proofread, standardize, and submit to the newspaper and post to our website.Arranging Local Obituary ServiceNo ObituaryNewspaper Obituary EstimateWe will prepare an obituary based on the information you provide. You will have an opportunity to proofread and edit the obituary prior to publication in the Reading Eagle. Costs shown below are ONLY estimates, are not inflation proof, and may increase at the time of death. If the obituary is longer than the samples shown, the price will be higher. The actual cost will be calculated at the time of death when the obituary has been submitted to the Reading Eagle. You will be responsible for any additional charges. Note: For publication in other newspapers, costs vary widely and are generally 4 or more times greater than the Reading Eagle's costs. Inclusion of a photo also adds to the cost. FREE: Limited to four lines.Obit without photo (brief): $175.00Obit without photo (long): $250.00Obit with photo plus details (long): $300Obituary Photo*Would you like us to use the same photo you uploaded for identification purposes or a different photo?Yes, use same photoNo, I will upload a different photoObituary Photo*Please upload a photo to be printed in the newspaper and on our website.Accepted file types: jpg. Save and Continue Later Package Options: Cemetery CostsBurial*Do you wish your cremains to be buried/placed in a mausoleum?YesNoCemtery*Have you already purchased a cemetery plot/niche and wish to use it for the applicant's interment?YesNoName of Cemetery*Opening and Closing Charges*Have you already paid the cemetery's opening and closing charges?YesNoUnsureCremation Vault*If your plot is at Forest Hills or Berks County Memorial Gardens, these cemeteries require an outer vault be placed around the urn for in ground burials. Have you already purchased this vault?YesNoUnsureNot neededCremation Vault: $595Forest Hills and Berks County Memorial Gardens require an additional vault for in-ground burial of cremains. You can purchase one as part of your preplan or order directly from the cemetery.Cremation VaultNone Save and Continue Later Package Options: UrnsHave you already purchased an urn?YesNoAt the time of death, a family member will need to deliver your purchased urn to our funeral home prior to the cremation process in order for cremains to be placed inside at the crematory. If the urn is supplied after cremation, a $50 transfer fee to place the ashes in the urn will be incurred. UrnsIncluded with this cremation package, the cremains are placed in a white corrugated box. You may upgrade to one of the following options. Please note: if you plan to bury in ground at a cemetery, an urn/vault is required. Some cemeteries, such as Forest Hills and Berks Memorial Gardens, also require an additional vault around the urn. Veterans, Spouses of Veterans and Dependent Children of Veterans: for burial at a National Cemetery, such as Fort Indiantown Gap, no urn or vault are needed.Corrugated box (included)Mailer/Niche Container: $25Tin: $25Burial Urn (unpolished stone): $295Burial Urn (cultured marble): $395Unpolished Color Options*Select a color for your urn.Catalina (tan)Nocturne (Black)Granitone (gray)Cultured Marble Urn Colors*Select a color for your urn.EmeraldWhiteCashmere GrayEbonyMystic BlueRoseGoldBerryWild RoseWedgewoodSilver GraySyroccoSky BlueColbaltAmethystMerlotBlack & GoldNavyEvergreenVerdeNeptuneCamoBlue & GoldBlack & WhiteWhite & BlackPinkSeafoam GreenCarreraSunset Orange Save and Continue Later Applicant InformationThe following pages relate to the person for whom arrangements are being made. If you cannot answer or do not know how to answer any of the required fields, please enter "unknown" in the field. When we receive your form, we will contact you to review the missing information.Gender*MaleFemaleOtherApplicant's Full Legal Name*No aliases or nicknames. First Middle Last Suffix Maiden Name*Last Name at Birth, Prior to 1st MarriageAliasAre you known by any other name? This does not include Nicknames. Save and Continue Later Applicant InformationApplicant's Address* Address Apt. # City State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY Zip Phone*Social Security Number*If unknown, enter 999-99-9999. Save and Continue Later Applicant InformationThe following are demographic questions that appear on the death certificate. Similar to the census, they help to track deaths based on race and ethnicity.Race*WhiteBlack or African AmericanAsian IndianOther AsianChineseFilipinoJapaneseKoreanVietnameseAmerican Indian or Alaska NativeNative HawaiianGuamanian or ChamorroSamoanOther Pacific IslanderOtherUnknownOther Race*Please enter your race below.Other Asian*Please enter your heritage below.Tribe*Please enter your Tribe below.Other Pacific Islander*Please enter your heritage below.Spanish Origin*This is a demographic question on the death certificate. Similar to the census, it helps to track deaths based on heritage.No, Not Spanish, Hispanic, LatinoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, Other Spanish, Hispanic, LatinoYes, Central AmericanYes, South AmericanYes, HaitianUnknownOther Hispanic*Please enter your heritage below.Pacemaker*Does the applicant have a pacemaker or other implanted device containing a battery?NoYes Save and Continue Later Applicant InformationApplicant's Date of Birth*If unknown, enter 01/01/2001.Country of Birth*United StatesState of Birth*Not ApplicableUnknownAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCity of Birth* Save and Continue Later Applicant Information: Birth ParentsFather/Parent 1 Name* First Middle Last Suffix Father/Parent 1 Status*LivingDeceasedFather/Parent 1 City and State*Mother/Parent 2 Name*Please include last name at birth, prior to 1st marriage (Maiden Name). First Middle Maiden Name Mother/Parent 2 Status*LivingDeceasedMother/Parent 2 City and State* Save and Continue Later Applicant Information: Marital StatusMarital Status*Never MarriedMarriedWidowedDivorcedSeparatedUnknown Save and Continue Later Applicant's SpouseSpouse's Name*Please include last name at birth, prior to 1st marriage (Maiden Name). First Middle Last, Suffix Maiden Name Spouse's Date of Birth*If unknown, enter 01/01/2001.Spouse's Social Security Number*If unknown, enter 999-99-9999. Spouse's Address*Does Spouse reside at the same address as the Applicant?Yes, Same as ApplicantNo, Different AddressSpouse Address* Address City State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY Zip Spouse's Phone* Save and Continue Later Applicant Information: School / WorkEducation*What is the highest grade/degree Applicant achieved?8th grade or less9-12th grade no diplomaHS Grad or GEDTrade Professional SchoolSome CollegeAssociate DegreeBachelor's DegreeMaster's DegreeDoctorateProfessional Degree (e.g, MD, RN)UnknownOccupation/Job Title*This is a census question asked on the death certificate. If the applicant held many jobs during his/her life, enter only one primary job title. Examples include, Accountant, Waitress, Steel Worker, Office Clerk, Homemaker, Police Officer. Do not enter Retired. If not known, enter unknown.Industry*This is a census question asked on the death certificate. For the occupation/job title you entered above, in what industry was this position held? Examples: Telecommunications, Medicine, Manufacturing, Restaurant, etc. If homemaker, enter "Own Home." If not known, enter unknown. Employer (optional)Name of Last or Most Significant Employer. Complete ONLY if you want this information included in the obituary.Years Employed (optional)How many years did the Applicant work here? Complete ONLY if you want this information included in the obituary.Other Employment Information (optional)Please provide any additional work details to be included in obituary. Complete ONLY if you want this information included in the obituary. Save and Continue Later Application Information: MilitaryMilitary Service*Did the Applicant ever serve in the Military or is a spouse of a veteran?NoUnknownU.S. ArmyU.S. Army Air ForceU.S. NavyU.S. MarinesU.S. Air ForceU.S. Coast GuardU.S. Army Air CorpMerchant MarinesNurse CorpNo, Spouse of ArmyNo, Spouse of Army Air ForceNo, Spouse of NavyNo, Spouse of MarinesNo, Spouse of Air ForceNo, Spouse of Coast GuardNo, Spouse of Army Air CorpDischarge Papers/DD214In order to establish eligibility for Veteran benefits, a copy of the Veteran's discharge papers (DD214) must be submitted. Please upload a scanned copy. You can also send a copy in when submitting your signed paperwork. If you do not have your DD214, we can still assist you in determining your eligibility if you are interested in burial at a National Cemetery, such as Indiantown Gap. If the spouse passed before the Veteran and has not yet been interred, a copy of the spouse's death certificate will also be needed in order to determine National Cemetery burial eligibility. Accepted file types: jpg, pdf.National Cemetery InternmentIf eligible, would you like to be interred at a National Cemetery? NoIndiantown Gap National CemeteryBurial at sea (Navy only) Save and Continue Later Obituary: Additional InformationReligious AffiliationIs the Applicant a member of a church? YesNoChurch NameChurch CityAdditional DetailsPlease include additional information for inclusion in the obituary, such as memberships in clubs, favorite pastimes and activities, interests and hobbies.DonationsWould you like to include a statement in the obituary about making donations in the Applicant's name?YesNoName of Organization for Donations Save and Continue Later Would you like to list suriviors in the obituary?YesNoSince you selected the brief newspaper obituary, you may wish to limit the number of survivors listed in order to keep costs low. One technique is to omit the residence (city/state) of each survivor and/or the spouse's name for each. Save and Continue Later Applicant's SurvivorsSurvivorsPlease enter the relationship, name, city and state of residence, and spouse's first name (and last name if different) for each survivor. Do not include Applicant's Spouse or Applicant's Parents as these have already been entered elsewhere. Do not include grandchildren. You will be asked about that in a later section. Do not include nieces, nephews, or cousins unless they are the only survivors. Click the "+" sign at the end of the row to enter an additional survivor. RelationshipFirst NameMiddle InitialLast NameCity, State of ResidenceSpouse's First Name DaughterSonStep DaughterStep SonSisterBrotherHalf SisterHalf BrotherStep SisterStep BrotherNieceNephewCousinCompanionFriend Save and Continue Later Grandchildren, Great Grandchildren, Great Great GrandchildrenPlease enter the number of surviving grandchildren, great grandchildren and great, great grandchildren. Optionally include names of each. NOTE: Adding names increases obituary length and cost.Predeceased Siblings and ChildrenPlease list names and relationship of all predeceased siblings and children. Save and Continue Later Consent*By submitting this form I understand that I am engaging John P. Feeney Funeral Home to provide the goods and services as I have selected herein. I understand that this agreement is not binding until all paperwork has been signed and returned to the funeral home and payment has been received. I attest that the information I have submitted is correct to the best of my knowledge. I understand I will be required to complete and submit any and all additional paperwork without meeting with the Director, unless I have selected the option above for a face-to-face meeting or this is an At-Need Situation. I agree. Save and Continue Later PaymentPayment is required in order to render your arrangements guaranteed inflation proof for our services and selected merchandise. All cash advance fees (i.e., Death certificates, Newspaper Obituary Estimate, and Clergy Offering) are not inflation proof and subject to change. Any increase in these costs will be payable at the time of death.Total for options selected $0.00 Payment Options*I will pay now with a credit credit.I will mail/drop off a check with my signed paperwork.Please note: If we do not receive payment, your contract will not be finalized and prices quoted herein are not guaranteed. Payment is required in order to render your arrangements guaranteed inflation proof for our services and selected merchandise. Please note: Payment is required when you come to the funeral home to sign the paperwork, unless other arrangements, such as insurance assignment, have been agreed upon. TERMS - This is a CASH transaction with full payment due by day prior to the service, unless other terms are agreed to, in writing, by this funeral home. If such an agreement is reached, a rebilling fee of $20.00 per month & late charge at the rate of 1.5% per mo. will be added to unpaid accounts over 30 days. Annual rate is 18%.Billing Information* First Last Billing Address* Street Address Address Line 2 City State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY Zip Code Billing Email* Save and Continue Later EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.