One of the advantages of prearranging your own funeral is that it plans for your final wishes prior to the time of need. This removes a huge burden from your family when you take care of the necessary funeral details and you provide all the information that we need. The following form allows you to send us the information we need to complete your prearrangements.
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Your Name
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Contact Phone
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Your Email
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Please enter the Decedents Name Below
For:
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Date of report:
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Decedents Information
Decedents Name (First, Middle, Last):
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Sex: Male
Female
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Social Security #:
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Date of Birth (Month, Day, Year):
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Marital Status:
Married
Never Married
Widowed
Divorced
Birthplace (City,
Was Decedent Ever In Armed Forces? Yes
If yes, Which Branch of Service?
Decedent Usual Occupation (most of life) :
Kind of Business/Industry
Surviving Spouse (if wife, give maiden name)
Residence State:
County:
City, Town or Location:
Street and Number:
Inside city Limits: Yes
Zip Code:
Was Decedent of Hispanic or Haitian Origin? Yes
If yes specify
Haitian
Cudan
Mexican
Puerto Rican
Other
Decedent Education (highest grade completed):
Father's Name: (First, Middle, Last)
Mother's Name: (First, Middle,Maden Name)
Living Next of Kin:
Mailing Address:
Type of Service:
Choice of Disposition of Body:
Burial
Cremation
Donation
Ship to another state
other
Items to be removed from body and returned to family:
Items to Remain in Casket for Disposition:
Place of Disposition of Body:
Location City or Town:
Visitation: Yes
No
If yes, Where :
Family View? Yes
Services (where and when):
Any type of Special Services:
Caske instructions:
Open Throughout
Closed throughout
Open, Close, Open
Open, Close, stay closed
Any Special Family Seating: Yes
No
Music: Yes
No
Clergy:
Church:
Family Car: Yes
No
Casket:
Vault:
Urn:
Clothing to be Worn:
Pallbearers:
Cemetery Information
Name:
Section:
Block:
Lot:
Space:
Other:
Disposition of Remains:
Special Notes to Funeral Home:
Newspaper Information
Deceased Name (including Nick Name if Any):
City of Residence :
Born in (City):
State:
On (Date):
Moved to this area on (date):
From (City):
State:
Occupation:
Employed By:
Was a Member of or Attended (church):
City :
State:
Was a Veteran of (war):
Branch of Service:
From (Dates):
Other Membership or accomplishments:
Memorial Contributions to:
Survived By
Survivor:
Relationship::
City
State:
Phone:
Zip:
Survivor:
Relationship::
City
State:
Phone:
Zip:
Survivor:
Relationship::
City
State:
Phone:
Zip:
Survivor:
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City
State:
Phone:
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Survivor:
Relationship::
City
State:
Phone:
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Survivor:
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City
State:
Phone:
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Survivor:
Relationship::
City
State:
Phone:
Zip:
