Information about person completing the form:
First:
Middle:
Last:
E-mail:
I am planning for:
self
spouse
mother
father
child
friend
other
Daytime Phone:
Evening Phone:
Fax (If available):
Personal Information about the person you are planning for
Death Certificate Information
First Name:
Middle Name:
Last Name:
Sex:
Male
Female
Marital Status:
Never Married
Married
Divorced
Widowed
Years of Education:
Street Address:
Mailing Address:
City:
County:
State:
Zip Code:
Length of Stay in County:
Is Home Address Inside City Limits:
Yes
No
Date of Birth:
City of Birth:
Hispanic Origin:
Yes
No
Race:
White
Black
Native American
Other
If other, specify:
Spouse's Full Name:
Spouse's Maiden Name:
Mother's Name:
Mother's Maiden Name:
Father's Name:
Military Service
Service Branch:
Serial Number:
Place Enlisted:
Date Enlisted:
Place Discharged:
Date Discharged:
VA Claim or File #:
Funeral Preferences
I Prefer The Funeral Service To Be:
Public
Private
Place Of Service:
Name Of Cemetery:
City:
State:
Grave or Niche Location:
Religious Denomination:
Church Affiliation:
Title of Person(s) to Conduct Service:
Elder
Priest
Clergyman
Rabbi
Reader
Name of Officiant:
Viewing For Family:
Yes
No
Viewing For Friends:
Yes
No
I Prefer:
Burial
Cremation
Other
For the family selecting cremation, what disposition of the remains would you prefer:
Musical Selections To Be Played:
Musical Selections To Be Sung:
Obituary Information
Survivor Name
Relationship
City
State
Person(s) To Finalize Arrangements At Time Of Death
Name:
Relationship:
Address:
Daytime Phone:
Evening Phone:
Second Contact
Name:
Relationship:
Address:
Daytime Phone:
Evening Phone:
Memorial contributions
can be made to:
Other Information / Special Instructions / Other People To Contact
Choose all that apply:
Please Call Me Best time to call:
AM
PM
Tell Me How To Pre-fund Funeral Expenses
Keep Information On File
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