The following form will allow family and friends to hold a funeral or memorial service with your preferences in mind. The information that you provide to us will be stored until such time that you wish to make changes or when your family needs to refer to it. We recommend scheduling an appointment with our counselors so we can better understand your preferences. Additionally, if you wish to fund your funeral through an inflation proof funeral plan, we will gladly assist you at a planning meeting.
Required fields are indicated by: *
First Name
Last Name
Address
City
State
ZIP
Home Phone
Cell Phone
Work Phone
E-mail
Date of Birth
Place of Birth
Father
Mother (maiden name)
Social Security Number
Highest Education Completed
Race
Veteran Yes No
If Veteran, please specify branch/rank
Occupation
Type of Business
Religious Affiliation/Membership
Other Organization Memberships
Spouse's Name
Date Married
Place Married
Number of Children (Deceased & Living)
Proceeded in Death by
Survivor-Spouse
Survivor(s)-Parent(s)
Survivor(s)-Children
Survivor(s)-Sister(s)
Survivor(s)-Brother(s)
Survivor(s)-Grandchildren
Survivor(s)-Great Grandchildren
Survivor(s)-Other
Location Where Funeral Should Be Held
Music
Visitation: Day 1 (Family)
Visitation: Day 1 (Friends)
Visitation: Day 2 (Family)
Visitation: Day 2 (Friends)
Cemetery
Marker Present Not Present
Open/Close Grave Funeral Home Family Cemetery
Clothing
Glasses Use Do Not Use
Glasses
Glasses After Service Bury Remove Donate
Jewelry After Service Bury Remove
Flowers Requested
Florist Preferred
Contributions Suggested To
Casket Preferred
Outer Container Preferred
Special Requests
Insurance Company
Policy Number
Amount
Family Contact
Relationship
Zip
Telephone Numbers
