Address: 701 12th St, Moline, IL, 61265, US
Telephone: 309-517-6539

Cremation Services and Membership: To become a member of the Cremation Society of the Quad Cities, please complete the following fields as much as possible or CLICK HERE TO DOWNLOAD AND PRINT A FORM. Before submitting you will be able to review all the information. Once received, our staff will prepare a certificate of membership, personalized wallet ID cards with our emergency contact numbers and a welcome letter. (Membership is not complete until we have all information.)
Name:*
First Middle Last
Current Residence Address:*
Street Address City State ZIP Code
Email:*
Phone Number:*
Member Date of Birth:*
Date Format: DD slash MM slash YYYY
Member Location of Birth:*
City State
Last Name prior to first marriage:*
Social Security Number
Gender:*
Highest Education:*
Primary Occupation (Prior to retirement)*
Type of Business/Industry*
Ever in Armed Forces? (If yes, please forward a copy of military discharge papers.)*
- No
- Yes
Father’s Name (as much as can be provided)*
First Middle Last Name (Prior to first marriage)
Mother’s Name (as much as can be provided)*
First Middle Last Name (Prior to first marriage)
Marital Status:*
Spouse’s Information, if living
First Middle Last Name (Prior to first marriage)
Authorizing Agent:*
First Last
The authorizing agent is the individual who is to be in charge when death occurs.
Relation to Member:*
Phone Number:
Email:
Person Filling out this information*
Name:
First Last
Phone:
Additional Information
Use this space to provide us with any details you would like us to keep on record:
Membership Fee: $49

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