I. Biographical Information
Full Name:
Date of Death:
Address1:
Address2:
City Name:
State:
Zip Code:
Telephone Number:
Email Address:
Date of Birth :
City of Birth:
State of Birth:
Highest Education Level:
- - Elementary Secondary College/University
Please select Grade/Years of Education completed:
-- 0 1 2 3 4 5 6 7 8 9 10 11 12
Social Security Number :
For security reasons, we will contact you to complete the pre-arrangement.
Residence History :
Father's Name:
Father's City of Residence:
Mother's Name:
Mother's City of Residence :
Mother's Maiden Name :
Spouse's Name:
Spouse's Maiden Name :
Survivors' Names and Cities of Residence
Relatives Who Have Preceded In Death
Occupation:
Business Type:
Company Name:
Church Membership :
Lodge or Union Name:
Veteran :
Yes No
Branch of Service :
None Army Navy Air Force Marines Coast Guard National Guard
Serial Number :
Date Enlisted :
Date of Discharge :
Rank at Discharge :
Location of a Copy of Discharge (DD214) :
Time of Military Service :
Not a Veteran Peacetime World War I World War II Korean War Vietnam War Persian Gulf War
Military Honors at Graveside :
Not a Veteran Yes No
Flag Preference for Service :
None Drape Casket with Flag Folded Flag on Casket
III. Service Preferences
Type of Service :
Chapel Service Church Graveside None
Visitation Hours :
Day Night None
Casket:
Open for service Closed for service No public viewing
Person in Charge of Arrangements :
Officiating Clergy :
Pallbearers :
Flower Preference:
Music Selection:
Jewelry:
No jewelry Give to family Leave jewelry on
Glasses :
No glasses Donate to Lions Club Leave on Give to family
Casket Preference :
Select a Casket Bronze Copper Stainless Steel Steel (sealing) Minimum Metal Mahogany Walnut Cherry Maple Poplar Pine Fiberboard / Veneer
Disposition :
Select Disposition Ground burial Mausoleum Cremation
Outer Container Preference: (for ground burial)
Select a Burial Container Bronze Triune Copper Triune Cameo Rose SST Triune Veteran Venetian Continental Monticello Minimum Grave Liner
Cemetery Name :
Cemetery Location:
The cemetery property is in the name of:
Miscellaneous Notes and Instructions :
Please select one of the options below :
