Information about person completing the form:

I am Planning for:

Choose One Myself Spouse Life Partner Mother Father Child Friend Other Relative

Last Name:

First Name:

Middle Name:

E-mail:

Street Address:

City:

County:

State:

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Zip Code:

Phone:

Vital Information about the person you are planning for:

Last Name:

First Name:

Middle Name:

Sex:

Choose One Female Male

Marital Status:

Choose One Never Married Married Divorced Widow Widower

Social Security#:

Date of Birth:

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (ex. 1999)

Place Of Birth:

Spouse's Full Name:

Spouse's Maiden Name:

Place of Marriage:

Date of Marriage:

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (ex. 1999)

Father's Full Name:

Mother's Name:

Mother's Maiden Name:

Work and Education:

Education:

Primary 0 1 2 3 4 5 6 7 8 9 10 11 12 College 0 1 2 3 4 5+

Usual Occupation:
(most of life)

Kind of Business:

Company (Optional):

Military Records:

Branch of Service:

Choose One Army Navy Air Force Marines Coast Gaurd Other

Serial Number:

Date Enlisted:

Rank At Discharge:

Date Discharged:

Discharge On File At:

Copy of Discharge Papers:   Yes No

Name Of  Wars:

Funeral Service Information:

Place Of Service:

Choose One Funeral Home Church Cemetery

City, State:

I Prefer The Funeral Service To Be:

Choose One Public Private

Viewing For Family:

Yes No

Viewing For Friends:

Yes No

Your Religious Denomination:

Your Regular Place Of Worship:

Your Lodge / Union Membership:

Person(s) To Finalize Arrangements At Time Of Death:

Check here and skip this section if  the same as person filling out this form.

Full Name:

Street Address:

City:

County:

State:

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Zip Code:

Phone:

Special Instructions:

Flower Preference:

Music

Casket Bearers

Jewelry:

Glasses:

Clothing:

Other:

Disposition Options:

I Prefer:

Earth Burial Mausoleum Cremation

Cemetery:

City, State:

Plot, Section:

I have made a last will and testament:   Yes No

Other Information & Special Instructions

Please list any other instruction or information you would like us to have:

Memorials & Charities

Please list any Memorials or Donations to Charity that you would like:

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