Arrangement Form

 

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.

 

 

Information About The Person Completing This Form

 

Date: .........................

            (month / day / year)

 

Name: ..................................................................................

                                          (First, Middle, Last)

 

Address: ...............................................................................

               ...............................................................................

               ...............................................................................

 

I am planning for (circle one):         Myself         Mother        Father

 

                                                     Aunt            Uncle           Other

                                               

Daytime Phone: .....................   Evening Phone: ...........................

 

E-Mail: ................................   Fax: .........................................

 

 

 

Personal Information About The Person You Are Planning For

 

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: ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

                                           ...........................................................................

 

 

 

Family Information

 

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

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

 

Newspaper to publish Death Notice: ...............................................................


Service Information

 

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 and/or Cremation Information

 

Cemetery Preferences: ..............................................................................

 

City: ............................................          State: .........................................

 

Deed Holder: .........................................................................................

 

Section: ........................         Lot: ...................       Block: ..........................

 

For the Family selecting cremation, what will be the final disposition of the cremated remains?

.........................................................................................................