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APPLICATION FOR BURIAL OR CREMATION GENERAL ASSISTANCEThe father, mother, grandfather, grandmother, children or grandchildren, by consanguinity, or the spouse or registered domestic partner (RDP) are responsible for the burial or cremation costs of the eligible person in proportion to their respective abilities. MRS Title 22, Chapter 1161, §4313 DECEASED NAME: _________________________ADDRESS: ____________________________________________DATE OF DEATH: ________________________AGE: ________SS#: _______________________________PEOPLE LIVING WITH THE DECEASED: ___________________________________________________________________ASSET: REAL ESTATE VALUE: $_____________________ MORTGAGE AMOUNT: $_____________________MOTOR VEHICLES/VALUE: _______________________ OTHER: ______________________________________________SOURCES FOR ASSISTANCE:SOCIAL SECURITY: $_________________DEATH BENEFIT: $________________VETERAN ADMIN.: $________________LIFE INSURANCE: $________________PENSION: $_______________BANK/ACCOUNTS: _______________________________________________________CONTRIBUTIONS FROM OTHERSFAMILY MEMBERSNAMEADDRESSTOWN/CITYSTATE/ZIPPHONE #AMOUNT ABLE TO PAYSPOUSE/RDP:$GRANDPARENTS:$$PARENTS:$$CHILDREN:$$$$$GRANDCHILDREN:$$$$$$PERSONAL REPRESENTATIVE OF THE DECEASED’S ESTATE:NAME: ____________________ PHONE #: _______________________ SIGNATURE: ____________________________ADDRESS: _________________________________________FUNERAL DIRECTOR’S NAME: ____________________________ PHONE #: ___________________________ADDRESS: ________________________________________DATE CONTACTED: ___________________________ ................
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