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Upon completion of this form you may choose from the following options located at the bottom of the form: "Submit this form for to be saved with the funeral home", "Submit this form to be filed but do not wish to be contacted at this time", "Submit this form and request to receive a General Price List", and "Submit this form and would like to be contacted".
Personal Information
First Name:
Middle Name:
Last Name:
Date of Birth:
Birthplace:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Email Address:
 
Father's Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:
 
Mother's Maiden Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:
 
Where were you raised and what schools did you attend?
 
Maiden Name of Spouse:
Date of Marriage:
Place:
If deceased, date of death:
 
Where have you lived during your adult life?
 
Name of children & their spouses, and their addresses
Child#1 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#2 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#3 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#4 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#5 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
 
Current Number of Grandchildren:
Current Number of Great Grandchildren:
 
Names of surviving brothers & sisters and their addresses
Sibling#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
 
Preceded in death by
 
Occupation. Give the type of work done most of working life, even if retired.
Name of Employer:
If Retired, Date of Retirement:
Total years spent in your occupation:
 
Church affiliation & activities:
List membership in fraternal, civic, or professional organizations:
 
Did you serve in the military? Yes No
If yes, what branch:
List membership in fraternal, civic, or professional organizations:
 
Special events in my life not listed previously:
 
FUNERAL INSTRUCTIONS
Place of Service:
Minister:
Minister:
Music Selections:
Organist:
Singer(s):
Singer#1:
Singer#2:
Singer#3:
Singer#4:
Singer#5:
Pallbearers:
Pallbearer#1:
Pallbearer#2:
Pallbearer#3:
Pallbearer#4:
Pallbearer#5:
Pallbearer#6:
Pallbearer#7:
Pallbearer#8:
Favorite Bible Selections:
Special Services (Military or Lodge)
 
Cemetery Information
Name of Cemetery:
Location City:
Lot is in the name of:
Section:
Lot:
Grave Space:
 
Casket and Burial Preferences
Casket:
Metal:
Wood:
Exterior Color:
Interior:
Burial Vault:
 
Authorized Persons to Arrange Final Details
Person#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
 
My Special Wishes
Clothing, jewelry, etc.
 
Form Submission Options
Submit this form to be saved with the Funeral Home
Submit this form but do not contact me
Submit this form and send me a General Price List
Submit this form and contact me
 
 
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