SECTION 1.   Vital Statistics (Needed to complete a death certificate)

First Name:         Middle Initial:          Last Name:  

Address: City: State      Zip:

Birthplace (City & State):         Date of Birth:

Father's First Name, Middle Initial:         Father's Last Name:

Mother's First Name & Middle Initial:         Mother's Maiden Name:

Choose One:        Married:*             Never Married:             Divorced:             Widowed:

*If Married, Spouse's Name:    First:         Middle Initial:         Last (Maiden Name, if applicable):

Occupation (even if retired):            Type of Business or Industry:

Social Security Number will be required at time of arrangements.

Military Service (Y/N):      If yes, Branch of Service:         Date of Entry (mm/dd/yyyy):     

Place of Entry:         Date of Discharge (mm/dd/yyyy):    

Do you AND your family know the location of your Discharge Certificate? (Y/N):

Discharge Certificate and Service Serial Number will be required at time of arrangements.

SECTION 2: Personal History (Needed for Obituary Notices)

                  List Organizational Affiliations (i.e. Church, Fraternal, Other):

                                                                   List Professional Achievements:              

                                                                                   List Schools Attended:   

Spouse's Name:         Date of Marriage (mm/dd/yyyy):     Surviving? (Y/N)

List Surviving Children:          List Surviving Brothers & Sisters:

# of Grandchildren:         # of Great Grandchildren:         # Great Great Grandchildren:

List Important Deceased Family Members (Relationship/Name):

SECTION 3: Memorial Instructions

Type of Service:              Funeral with Viewing:           Funeral with Family Viewing Only:            Funeral with No Viewing:       

                                                                              Graveside Only:             Memorial Service Only:

Place of Service:             Funeral Home:             Church:             Graveside Only:             Other (list):

Casket (Made from): Bronze:   Copper:   Stainless Steel:   Steel:       Wood:        List Wood Type: Mahogany Cherry Maple Oak Ash Pecan Poplar Pine Cloth Covered       

Casket Color:                   Exterior:                     Interior:              

Outer Burial Container:        Lined Top Seal:             Air Seal:             Unlined Top Seal:             Grave Liner:

List Special Instructions:         Such as Clergy, Military Honors, Flowers, Music (songs, musicians, soloists), Favorite Scriptures to be read, Clothing to be used, Jewelry, or any other instructions that will be helpful to your family.

Disposition Information:                Burial:                                If Burial, List Cemetery:

                                                      Cremation:                        Cremains Disposition Instructions:

Please Contact Me for a Face to Face Appointment (Y/N):           Contact Phone #:

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