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Personal Information
First Name:
Middle Name:
Last Name:
Date of Birth:
Birthplace:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Email Address:
 
Father's Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:
 
Mother's Maiden Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:
 
Where were you raised and what schools did you attend?
Highest level of education:
 
Maiden Name of Spouse:
Date of Marriage:
Place:
If deceased, date of death:
 
Where have you lived during your adult life?
 
Name of children & their spouses, and their addresses
Child#1 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#2 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#3 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#4 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#5 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
 
Current Number of Grandchildren:
Current Number of Great Grandchildren:
 
Names of surviving brothers & sisters and their addresses
Sibling#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
 
Preceded in death by
 
Occupation. Give the type of work done most of working life, even if retired.
Name of Employer:
If Retired, Date of Retirement:
Total years spent in your occupation:
 
Church affiliation & activities:
 
Did you serve in the military? Yes No
If yes, what branch:
List membership in fraternal, civic, or professional organizations:
 
Special events in my life not listed previously:
 
Funeral Instructions
Place of Service:
Minister:
Minister:
Music Selections:
Organist:
Singer(s):
Singer#1:
Singer#2:
Singer#3:
Singer#4:
Singer#5:
Pallbearers:
Pallbearer#1:
Pallbearer#2:
Pallbearer#3:
Pallbearer#4:
Pallbearer#5:
Pallbearer#6:
Pallbearer#7:
Pallbearer#8:
Favorite Bible Selections:
Special Services (Military or Lodge)
 
Cemetery Information
Name of Cemetery:
Location City:
Lot is in the name of:
Section:
Lot:
Grave Space:
 
Casket and Burial Preferences
Casket:
Metal:
Wood:
Exterior Color:
Interior:
Burial Vault:
 
Authorized Persons to Arrange Final Details
Person#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
 
My Special Wishes
Clothing, jewelry, etc.
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