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*:
Zip code*:
Daytime phone*:
Evening phone:
Sex:  Male     Female
Social security number:
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:
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
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
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    
 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:
Burial vault:
Special wishes (clothing, jewelry, etc):
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)
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:,
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.