(214) 376-8297
bcfh@blackandclark.com
2517 East Illinois Ave.
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Deceased Information
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Informant Information
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Survivor Information
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Disposition Information
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Funeral Service Information
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Goods and Services
Funeral Home Information
Funeral Home Registration #:
3351
Funeral Director Name:
Emanuel Pruitt
Gary D. Clark
Embalmer Name:
Emanuel Pruitt
Name & Residence
Case ID:
Title:
Select Title
Mr.
Mrs.
Miss
Ms.
Dr.
Other
First Name
*
:
Middle Name:
Last Name
*
:
Suffix:
Nickname:
Maiden Name:
Deceased's Residence
Address:
City:
Country:
State/Province:
Zip/Postal code:
County:
Location:
City
Village/Borough
Town
Within City or Village Limits:
Yes
No
Years at Residence:
Formerly of:
Place of Death
Date of Death
*
:
Time of Death:
Time Unknown:
Yes
Place of Death Type:
Select
Nursing Home
Private Residential
Hospice
Inpatient
Outpatient
DOA
ER
Other
If Facility, Date Entered:
Same as Deceased's Residence
Place of Death:
Address:
City:
Country:
State/Province:
Zip/Postal code:
Phone:
Phone Ext:
County:
Location:
City
Village/Borough
Town
In City Limits:
Yes
No
Coroner Contacted:
Yes
No
Cause of Death:
Length of Illness:
Medical Record Number :
Death Registration Number:
Date Permit Issued:
Was Decedent Transferred:
Yes
No
Date Entered:
Institution:
Address:
City:
Country:
State/Province:
Zip/Postal code:
Phone:
County:
History
Date of Birth:
Social Security Number:
City of Birth:
State of Birth:
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
County of Birth:
Country of Birth:
USA
Other
Race:
White
American Indian or Alaska Native
Asian Indian
Black
Chinese
Filipino
Guamanian or Chamorro
Native Hawaiian
Indian
Japanese
Korean
Samoan
Vietnamese
Other Asian
Other Pacific Islander
Other
Hispanic Origin:
Chicano
Cuban
Mexican
Mexican American
Puerto Rican
Other
Education & Occupation
Education Specific:
8th Grade or Less
9th-12th (no Diploma)
HS Graduate or GED
Some College (no Degree)
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate or Pro Degree
Education Notes:
Occupation:
Number of Years:
Kind of Business:
Company Name and Location:
Retired:
Select
Yes
No
Year Retired:
Work History:
Parent's Information
Same as Deceased's Residence
Father First Name:
Father Middle Name:
Father Last Name:
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
Date of Birth:
Deceased:
Date of Death:
Place of Birth:
Same as Deceased's Residence
Mother First Name:
Mother Middle Name:
Mother Last Name:
Mother Maiden Name:
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
Date of Birth:
Deceased:
Date of Death:
Place of Birth:
Marital Information
Marital Status:
Never Married
Married
Separated
Divorced
Widowed
Unknown
Spouse Title:
Select
Mr.
Ms.
Mrs.
Miss
Dr.
Other
Same as Deceased's Residence
Spouse First Name:
Spouse Middle Name:
Spouse Last Name:
Spouse Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
Date of Birth:
Deceased:
Social Security Number:
If Married - Date Married:
Place of Marriage:
If Widowed, Date Widowed:
Military Status
Served in Armed Forces:
Yes
No
Unknown
Start Date:
Start Place:
End Date:
End Place:
Name of War:
Select
World War II
Korean
Vietnam
Persian Gulf
Afghanistan
Iraq
Other
Branch:
Select
Air Force
Army
Army Air Corps
Coast Guard
Marine Corps
Merchant Marine
Navy
Reserves
Other
Rank / Grade:
Medals Awarded:
Medal of Honor
Dist. Service Cross
Navy Cross
Air Force Cross
Bronze Star
Silver Star
Purple Heart
Other Medals:
Service Number:
VA File Number:
Honors to be rendered:
Cemetery
Chapel
Funeral Home
Other
Marker Box
Date Marker Ordered:
Ordered by:
Type of Marker:
Bronze Niche
Flat Bronze
Flat Granite
Flat Marble
Upright Granite
Upright Marble
Small Flat Granite
Emblem:
Aaronic Order Church
Atheist
Bahai 9 Point Star
Buddhist
Christian
Christian and Missionary Alliance
Christian Church
Christian Reformed Church
Christian Science Cross and Crown
Community of Christ
Eckankar
Episcopal Cross
Greek Cross
Hindu
Islamic 5 Pointed Star
Judaism
Konko-Kyo Faith
Lutheran Cross
Mormon-Angel Moroni
Muslim Crescent and Star
Native American Church of America
None
Presbyterian Cross
Russian Orthodox Cross
Seicho-No-Le
Servian Orthodox
Sufism Reoriented
Tenrikyo Church
The Church of World Messanity
Unitarian Church Flaming Chalice
United Church of Christ
United Church of Religious Science
United Methodist Church
United Moravian Church
WICCA (Pentacle)
Ship To:
Funeral Home
Cemetery
Informant
Flag Recipient
Date Received:
Date Family Called:
Who Called Family:
Date Picked Up:
Picked Up By Whom:
Notes:
Flag Receiver
Same as Spouse
Same as Father
Same as Mother
Flag Receiver First Name:
Flag Receiver Middle Name:
Flag Receiver Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
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Home
About Us
Our History
Our Staff
Map & Directions
Our Facilities
Contact Us
Testimonials
Funeral Planning
When Death Occurs
Burial Services
Cremation Services
Eulogies & Obituaries
Funeral Etiquette
Pre-Need
About Pre-Planning
Make Pre-Arrangements Online
10 Facts about Grief and Grieving
Resources
Grief Resources
Legal Advice
FAQ
Covid-19 Funeral Assistance
Understanding Bereavement
Obituaries & Tributes
Obituaries
Send Flowers
