Preplanning Form

Personal Information
I'm planning for*:
Your Name*:
Email address*:
 
Person you are pre-need planning for.
Full legal name* :
Date of birth*: mm/dd/yyyy example: 01/31/2012
Street address*:
City*:
State*:
Zip code*:
Daytime phone*:
Evening phone:
Sex:  Male     Female
Social security number:
Race:
Hispanic origin:  Yes     No
If Yes, specify:
Occupations and employers:
Business or industry:
Any addition information on occupations held and places of employment:
Last position held:
How long at last position:
Retired:  Yes     No
If retired - then year retired:
Last residence:
Length of time living:
High school graduated from:
Education:
College's - years attended and degrees earned:
Clubs, fraternal organizations:
Hobbies / affiliations / lodges / memberships / church attended / obituary info / etc:
Comments / questions or additional info:
Church affiliation:
UAW member or member of any other union: (please specify local #)
Marital status:
Spouse's full legal name:  (First, middle, last - if wife include maiden name)
Date of marriage:  mm/dd/yyyy example: 01/31/2012
Place of marriage:
If spouse is deceased - then date of death:  mm/dd/yyyy example: 01/31/2012
Father's legal name:  (First, middle, last name)
Father's birthplace:
Mother's legal name:  (First, middle, maiden name)
Mother's birthplace:
Mother's maiden name:
 
Veteran's information
Branch of service:
War service and awards:
Enlistment date (if known):
Enlistment place (if
Rank at discharge:
Discharge date:
Service number:
 
Person responsible for funeral arrangements
Name:
Address:
Phone:  example: 404-404-7000
Email address for obituary:
 
Family members:
Please list surviving family members below, name and relationship, including spouse, children, parents, grandparents, brothers, sisters, grandchildren, etc., and city/state where they are currently living.
Predeceased by the following family members:
(name and relationship to deceased)
 
Service information
Please select one of the following as your preference:
 Traditional Funeral Service  Traditional Cremation Service
 Graveside Burial Service  Memorial Cremation Service
 Immediate Burial  Graveside Cremation Service
   Direct Cremation
Clergy:
Cemetery:
City & State:
Deed in the name of:
Location: (Section, Block, lot, Grave No.):
Marker Installed:  Yes     No
Name of cemetery/Property owner:
Special instructions:
Services to be held at:
 Funeral home
 Church / Church name    
 Other / Specify    
 Graveside
 Rosary
 Prayer service
If a Veteran, is the flag to be:  Draped     Folded
Please list any musicians and music selections:
Pallbearers (Name/phone no. if you would like for us to notify them):
Honorary pallbearers:
Casket Material:
Exterior color:
Interior:
Burial vault:
Special wishes (clothing, jewelry, etc):
Newspapers
The funeral home will notify the local newspaper (within your community).
What other papers should be notified:
Photo in the obituary:  Yes     No
Local emergency contacts to be notified at time of death:
(please include full name, address, phone, email address and their relationship):
 
Important legal information for family use (not required)
Will location:
Attorney name and contact information:
(please include full name, address, phone and email information)
Executor of estate:
(please include full name, address, phone and email information)
Safety deposit box location:
(please include institutions name, address and phone information)
Additional information:
(please include insurance policies, etc)
Living will:  Yes     No
Living trust:
Receiving VA benefits:  Yes     No    (funeral home will notify at time of death)
If yes, are you a disabled  Yes     No
Receiving pension:  Yes     No    (funeral home will notify at time of death)
Receiving social security:  Yes     No    (funeral home will notify at time of death)
 
Personal
The people who have had the greatest and most profound impact on my life have
Some of the accomplishments that I am most proud of are:
My fondest memories include:
If I could live my life over again, I would spend less time:
Is there a special story about you or your loved one's heritage you would like to share:
Do you or your loved one have a favorite scripture, song, saying or poem:
What lasting memory will those who knew you or your loved one remember:
How would you or your loved one want to say goodbye and
what messages would they / you like to leave:
 
E-mail notifications at time of death to be sent to:
please separate each email address by a comma. (ex: me@ex.com, you@ex.com)
Bible passages, poetry, quotations, verses, etc and who should read them:
Participating organizations (List all that apply including Masonic Lodge and its number, Veterans/VFW
lodge and its number, Knights of Columbus, Lions Club and any other Fraternal / Military Rites):
Memorial contributions to:
Address, where pre-arrangement documents can be delivered: (address, phone, contact)
Please call me:  Yes     No
Tell me how to pre-pay expenses:  Yes     No
Keep my information on file  Yes     No
 
 
If you would like to speak with someone at any time, or have questions in regards to
the pre-arrangement process or this document, please feel free to contact anyone of
our knowledgeable, friendly staff at (334) 677-7200.