Prearranging a funeral often provides peace of mind for both the individual and their family. We encourage as much preplanning as possible. The best decisions tend to be made when there is sufficient time to ask questions and make more informed decisions and choices.

Please answer the questions on the following form as correctly as possible. This is our permanent record from which data is taken to compile obituaries as well as forms and certificates required by law.

Prearrangement Form
Legal name for death certificate
Name for obituaries
City of residence
City formerly of
Date of birth
City of birth
County of birth
State of birth
Physician’s name
Physician’s address
Physician’s Phone number
Length of residence in community
Residence within city limits	YesNo
If foreign born, how long in U.S.A
Marital status	MarriedNever MarriedWidowedDivorced
Spouse (If wife, include maiden name)
Date & place of marriage
Date & place of death (If spouse is deceased)
Name of father
Living or deceased	LivingDeceased
Name of mother (Include maiden name)
Living or deceased	LivingDeceased
Primary occupation
Years spent in occupation
What kind of industry
Military service of U.S.A	YesNo
Branch of service
Which war(s)
Date & place of induction
Date & place of discharge
Rank
Number of years of education
Schools and degrees
Person providing this information
Informant’s mailing and/or street address
City, State, Zip
Phone number
Email address (For forwarding Internet condolences)
Name of Cemetery or Crematory
Street and/or mailing address
City, State, Zip
Phone number
Section
Lot
Space
Name of lot owner
Spouse Full Name
Street & Mailing Address
City, State, Zip
Phone number
Enter Children Names, full addresses & phone numbers
Enter Parents Names, full addresses & phone numbers
Enter Siblings Names, full addresses & phone numbers
Grandchildren & Great-grandchildren List number of and how the names are to be listed in the obituary
Service and Visitation
Place of service
Time of service
Day & date of service
Clergy 1
Clergy 2
Clergy 3
Place of visitation
Time of visitation
Day & date of visitation
Flowers	YesNo
Memorial donations to
Church affiliation
Lodge affiliations
Pall Bearers
Newspapers to contact
Notes & Additional Obituary Information
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