This form has been designed to help gather the information that will be needed to complete a funeral arrangement. If all the information is not complete, it will not preclude you from making prearrangements. You can use this form as a record of your funeral preferences or the preferences of a loved one.
Date: .........................
(month / day / year)
Name: ..................................................................................
(First, Middle, Last)
Address: ...............................................................................
...............................................................................
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I am planning for (circle one): Myself Mother Father
Aunt Uncle Other
Daytime Phone: ..................... Evening Phone: ...........................
E-Mail: ................................ Fax: .........................................
Name: ..................................................................................
(First, Middle, Last)
Residence Address: ..................................................................
Town: ..................................................................................
County: ................................................................................
State: .................................. Zip Code: ..............................
How long a resident of this city: ....................................................................
(Years)
Formerly of: ...........................................................................................
Telephone: .............................................................................................
SS#: ....................................................................................................
Marital Status: ......................... Sex: ....................................................
Husband/Wife of: ....................................................................................
Surviving: ................................
(Yes/If No – Year)
Birth Place: .............................. Date of Birth: ..................................
Fathers Name: .......................................................................................
(First, Middle, Last)
Mothers Maiden Name: .................................................................................
(First, Middle, Last)
How Long in the US: ...............................................................................
Hispanic Origin: ................................ Race: .................................
Military Service: ............................... War: ..................................
Date entered: ................................... Date discharged: ...................
Years of Education: ...........................
Occupation (give position held): ........................................................................
Employer’s name: ...................................................................................
Employer’s Address: ................................................................................
...............................................................................
Kind of Business: ...................................................................................
Retired: ........................................ Year: .......................................
Church Member of: ..................................................................................
Organizations Member of: ...........................................................................
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The information gathered here will be used in the news paper notice. There is a charge, determined be the paper by the line. The listing of children’s spouse, Grandchildren’s name, etc. will increase the line charges.
List Spouse First
Children – with or without spouse – oldest to youngest
(Ex. - John Doe Son Paramus)
(Ex. - John Doe and Jane Son Paramus)
Siblings – oldest to youngest
Grandchildren - number
Great-grand children – number
If anyone below predeceased the person for whom this prearrangement is for please list them and enter the year of death in the city and state column.
Name Relationship City & state
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Newspaper to publish Death Notice: ...............................................................
I would prefer the services to be (circle one): Public Private
Days of Viewing: 1 Afternoon 1 Evening 1 Afternoon and 1 Evening
1 Afternoon and 2 Evenings 2 Afternoons and 2 Evenings
3 Afternoons and 3 Evenings Other
Place of Service: Church Funeral Home Other
Cemetery Preferences: ..............................................................................
City: ............................................ State: .........................................
Deed Holder: .........................................................................................
Section: ........................ Lot: ................... Block: ..........................
For the Family selecting cremation, what will be the final disposition of the cremated remains?
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