Funeral Planning Form

Personal Information
Full Name:
Marital Status:
Birth Date:    Birth Place:
Father's Full Name:
Mother's Full Maiden Name:
Name as you want listed in obituary:
Current Address:
City:    State:
Zip:    County:
Home Phone: Cell Phone:
E-mail:
Spouse's Name:
If wife - Full Maiden Name:
Spouse Cell Phone:

Work/Education History
Education (0-12):                 College 1-5+:
Briefly list your work history:

Military Record
Branch of Service:
Serial Number:
Date Enlisted:    Date Discharged:
Rank At Discharge:
Discharge On File At:
Copy of Discharge Papers: Yes No
Name Of Wars:

Funeral Service Request
Location of Service:
City & State:
Phone:
Visitation:
Religious Denomination:
Place Of Worship:

Surviving Family (Please list family members)
Please give detailed information John Doe and wife Mary of Mexico, Missouri
Parents:
Son(s)
Daughters(s)
Brother(s)
Sister(s)
Grandchildren (number):   Great-Grandchildren (number):
Other significant relatives:
Family Members already deceased (list relation):

Special Instructions
Jewelry:
Glasses:
Clothing Preference
Lodge, Union, Organization Memberships:

Disposition Request
I Prefer:
Cemetery:
Address:
Phone:
Section:

Other Instructions
Memorials/Donations To Charity
Please select all that apply:

Send information about pre-arrangement
Contact me to set an appointment
Please keep my information on file
verification image, type it in the box

"Four generations of family serving families in and around Mexico"