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Pre-Arrangement Guide

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Personal Data For

Vital Statistics

Legal Name (and nickname)

Address, City, State, Zip

Date of Birth Place of Birth

Father's Name

Mother's Name & Maiden Name

Highest Grade in School Completed (For Death Certificate Only)

Number of years at present address

Occupation:

If you wish, number of years of work and name of work place.

Veteran, Yes No If yes, we would need a copy of the person's discharge papers, in order to make application for V.A. Benefits, which will be discussed later.

SS# Living spouse maybe eligible for $255.00 lump sum death benefit. Our funeral home will notify Social Security that there has been a death.

Marital Status

Date of Marriage

Spouse's Name (Include Maiden Name)

Place of Marriage

(Previous marriages, names, dates of marriage, and dates of death, if you would like to list them:

____________________________________________________________________

List of Survivors and City, State of Residence:

List of those who have preceded you in death:

____________________________________________________________

List of Church membership, Organizations, and/or other information:

Funeral Service Requests

Place of Service

Officiating Minister

Organ Music Vocal Music Piano Music

CDs or tapes _________

List of Hymns, play or sung:

Preference of Pallbearers: Usually six men serve as pallbearers, some individuals have a preference of who the funeral home is to contact.

Preference of Fraternal Services held during the evening of visitation, i.e. Masons, Eastern Star, Elks, etc. or you may wish to have Military Services conducted at the cemetery. Please list all services that you would wish to have.

Cemetery Name for Burial

City, State, Zip

Section

Lot number Block number

Space number

If the lot number and other space information is not known, please list who is already buried on the lot, or who has a marker or monument on the lot and where you wish to be buried in relation to that information, like, next to my mother's grave or to the east of my father's grave.

Some people do not wish to have any services. Some individuals may wish to be cremated, but have a night of visitation and a funeral service. Or you may have other very specific requests. Please be as specific as you can.

Persons To Be Notified

I have filed copies of this Record with the following:

I respectfully request that the above suggestions be considered as closely as possible in completing my final arrangements.

Signature