— Seeking Victim Information in Return to Nature Funeral Home

Your Contact Information

First Name

Middle Name

Last Name

Date of Birth (mm/dd/yyyy)

Best Contact Number

E-Mail Address

Address Line 1

Address Line 2

City

State

Country If not USA

ZIP/Postal Code

Relationship to the Deceased:

Spouse/partner of the deceased
Child of the deceased
Sibling of the deceased
Parent of the deceased
Power of attorney of the deceased

Best time to call:

Morning
Afternoon
Evening

The Deceased’s Identifying Information

First Name

Middle Name

Last Name

Date of Birth (mm/dd/yyyy)

Date of Death (mm/dd/yyyy)

Questions

1. What company did you use for the decedent's final arrangement?

2. Who did you primarily work with at the company? Provide name and contact information (address, work phone, cell phone, e-mail, etc.)

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3. What was the final disposition of the decedent?

Burial
Cremation
Donation
Other

3a. If other, please specify

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4. How much did you pay the company in total?

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5. How did you pay?

Cash
Personal Check
Funeral Insurance
Credit Card
Other

5a. If other, please specify

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6. What documents do you have from the company?

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7. If cremated, do you still have the cremains?

Yes
No

7a. If yes, where are the cremains located?

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8. Please include any other information that you think is important to the investigation.

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Questions 9-18 pertain to the decedent.

9. Name of Primary Doctor?

10. Name of Primary Dentist?

11. Describe scars or tattoos?

12. Was hospice care used? Where?

13. Any Medical devices?

14. Which Return to Nature location was used?

15. If your loved one was cremated, what company is listed on the death certificate as performing the cremation?

16. Please describe what your loved one was last wearing.

17. Were they wearing any jewelry to be buried/cremated with them?

18. Did you provide Return To Nature (RTN) with any other objects to be buried/cremated with them? (please describe)

Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/doj-systems-records#doj

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Seeking Victim Information in Return to Nature Funeral Home

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