General Information

I am planning for:   Please Select self spouse parent child sibling relative friend

Your Information

First Name:  

Last Name:  

Address 1:  

Address 2:

City:  

State:   AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY

Zip/Postal Code:  

Daytime Phone:

Evening Phone:

Email Address:

Information about the person this plan is written for

First Name:  

Middle Name:  

Last Name:  

Date of Birth:  

Birthplace:  

Address 1:  

Address 2:

City:  

State:   AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY

Zip/Postal Code:  

Personal Information-Family

Fathers Full Name:  

Address 1-if living:

Address 2-if living:

City:

State:

Zip/Postal Code:  

Mothers Full Maiden Name:  

Address 1-if living:

Address 2-if living:

City:

State:

Zip/Postal Code:  

Where were you raised at what schools did you attend?

Highest level of education:

Maiden name of spouse:

Date of marriage:

Place:

If deceased, date of death:

Where have you lived during your adult life?

Names of children and their spouses:

Current number of grandchildren:

Current number of great-grandchildren:  

Names of surviving brothers and sisters:

Preceded in death by:

Employment Information

Occupations-give the type of work done most of working life:

Name of Employer:

Address 1:

Address 2:

City:

State:

Zip/Postal Code:  

Phone:

If retired, date of retirement:

Total years spent in your occupation:

Church affiliation & activities:

Did you serve in the military?     Yes     No

Branch of Service:   Please Select Air Force Army Coast Guard Marines Navy

List membership in fraternal, civic, or professional organizations:

Special events in my life not listed previously:

Funeral Instructions

Place of Service:

Minister (1st choice):

Minister (2nd choice):

Music Selections:

Organist:

Singer:

Names of pallbearers (6):

Favorite bible selections:

Special services (military or lodge):

Disposition Preference:   Please Select Burial Entombment Cremation No Preference

Service Preference:      Please Select Traditional Funeral Service Graveside Burial Service Immediate Burial Traditional Cremation Service Memorial Cremation Service Graveside Cremation Service Direct Cremation  

Cemetery Information

Name of Cemetery:

City/State:

Lot is in the name of:

Section:

Lot:

Grave #:

Casket & Burial Preferences

Casket name:

Metal            Wood

Exterior Color:

Interior Color:

Burial Vault:

Authorized persons to arrange final details

Person 1-name:

Address 1:

Address 2:

City:

State:

Zip/Postal Code:

 Phone:

Person 2-name:

Address 1:

Address 2:

City:

State:

Zip/Postal Code:

 Phone:

Special Wishes

Clothing, jewelry, etc.