Full Name:

Address:

Place of Birth: Date of Birth:

Father's Name: Mother's Maiden Name:

Spouse (if wife maiden name):

If widowed, date of death:

Marriage date and place:

Usual Occupation:

Social Security Number: National Decent:

Number of Years of School Completed:

Church Membership or Affiliation:

Veteran: Yes No War: Dates of Service:

Are you (or was deceased) receiving military pension? Yes No

The following section is for suggestions and preference concerning funeral services. These will be offered to the family at the time of an arrangement conference and will be offered as your suggestions unless you signify below that they are to be absolute plans.

MUSIC

Song Preferences:

Singers: , ,

Accompanist:

Casketbearers: Six should be listed if you have a preference, and possible alternates. Honorary casketbearers are not a necessity and may sometimes cause hard feelings if somebody close is forgotten.

Should services be held at a church or the mortuary?

Name of minister I would suggest, or a minister from what church?

Are there any lodge or veteran's rites I would prefer?

Name of Cemetery I prefer, and location, also lot number or location.

PLEASE LIST SURVIVORS: Sons, daughters, brothers, sisters. Please list the town and state they reside in. List the number of grandchildren, great-grandchildren and great-great-grandchildren. Also list preceding deaths.

1. Grew up Where, Schooling, early work life?

2. Places lived, occupations (chronological order)

3. Organizations, activities?

Please provide your email address and phone # so we can reach you with any questions:

email: phone #: