Biographical Form

PLEASE NOTE: If you have entered information after hours, and need immediate assistance, please call 1 (845) 331-1473 or use our web chat feature.

Please read carefully, this section contains information that we are required to gather, by New York State law. Please answer each question to the best of your ability. If you do not have this information, or are unsure, please enter "Unknown". We will review this information with you. Thank you

Contact Person

First Name*:

Middle Initial:

Last Name*:

Address:

City:

State:

ZIP Code:

Email*:

Best Phone To Be Reached At*:

Alternate Phone:

Relationship to Deceased*:

If you selected Other, please specify

Beneficiary Information: (who plan is for)

Please answer to the best of your ability:

First Name*:

Middle Initial:

Last Name*:

By NYS Law, we cannot use PO Box as address, please enter physical address, use house number, mailbox number or
911 fire number. If you are not sure, we will review with you. Please complete to best of your ability.

Address:

City:

State:

ZIP Code:

Date of Birth*:

(city, town, village)

Place of Birth*:

State*:

MUST follow xxx-xx-xxxx

Social Security Number*:

Ethnic Origin*:

If of Hispanic decent:

If you selected Other on etheir of the previous two selections, please specify

Education*:

Employment Of Beneficiary

Even if retired, NYS Law requires this information. If disabled, please enter disabled, if unknown, please enter
unknown, if homemaker, please enter homemaker, if self employed, please enter type of self employment. We also
understand a person may have had several occupations, but NYS law allows only one entry.

If you are not sure, please enter “unsure” we will review with you.

Example - carpenter, teacher, administrator

Occupation/Job title*:

Example - construction, education, technology

Kind of Business/Industry*:

Example - Carpenters Local #123, Kingston Consolidated Schools, IBM Kingston

Name & Local*:

Father of Beneficiary

If you do not have this information insert 'Unknown'

First Name*:

Middle Initial:

Last Name*:

Mother of Beneficiary

If you do not have this information insert 'Unknown'

First Name*:

Middle Initial:

Last Name*:

Marital Status

By NYS state law we are required to gather this information - Please note, if wife is surviving, provide maiden
name.

If you do not have this information, please insert 'Unknown'

Marital Status*:

List 1st name, Last name. - If wife, list First name then Maiden name.
If not or never married or if you do not have this information insert 'Unknown'

If Married Spouse's Name*:

Military Status

It is very important that we have as accurate information as possible. A veteran is entitled to many benefits,
with out the proper documents, we will not be able to help you file for those benefits. If you don’t know,
please enter unsure.

We will do everything possible to make sure the veteran receives all the benefits they have earned by serving
our country.

In Armed Forces*:

If Yes, Branch Of Service:

Name of War:

If you selected unsure, please specify

If not, we may be able to help you obtain a copy

Do You Have Discharge:

Year range - Example: 1950 - 1955

Year Served:

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We are honored to help you through this difficult time.Your loved one never leaves our care.