Pre-Planning Form

This Form can be completed to begin the pre-planning process

Personal Information
First Name (required)
Middle Name
Last Name (required)
Date of Birth
Place of Birth (City,State)
Current Address
City/Village
State Zip County
Township
Phone Number
Email (required)
Marital Status
Spouse Full Name
Spouse's Maiden Name
Place of Marriage
Date
Father's Name
Mother's Name
Mother's Maiden Name
Race
College
Occupation
Business
Company
Military Information
Were you in the military?
yes no
Branch
Service Number
Date Enlisted
Date Discharged
Rank at Discharge
Where is your Discharge on file?
Do you have a copy?
yes no
Do you want military honors?
yes no
Funeral Service
Location
Visitation
Religious Denomination
Place of Worship
Lodge or other memberships
Person in Charge of Funeral Arrangements
Special Instructions
Flower Preference
Music Preference
Casket Bearers (6 to 8)
Jewelry
Glasses yes no
Clothing
Other
Donations/Memorials
Disposition
I Prefer
Cemetery
Location of Cemetery
Section/Lot Number/Etc.
Do you have a headstone? yes no
Have you made a last Will and Testament ? yes no
Location of Will and Testament
 
Survivor Information
Please list your immediate next of kin (Parents, Siblings, Children, Grandchildren, & Great Grandchildren) including place of residence:
 
Other Information
Please list any other details that you would like to add:
 
Please select your preferred option below (Check any or all):
Send information about pre-arrangement
Contact me to discuss details
Please keep my information on file