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This form is provided as a service to allow you to record funeral preferences for yourself or a loved one. Once you have filled in the information you may:
  • Choose one of the submit buttons at the end of the form
  • Or print the completed form and place it with your important papers
Personal Information of Planner:
First:
Today's Date:
Middle:
I am Planning For:
Last:
 
Daytime Phone:
Evening Phone:
Fax:
 
Email:
Personal Information of Pre-Deceased:
(Use Full Legal Name)
First:
Sex:
Middle:
Marital Status:
Last:
Education Level:
Date of Birth:
Place of Birth:
Street Address:
City:
Mailing Address:
State:
Country:
Zip Code:
Length of Stay in Country:
Is Home Address Inside City Limits:
Smoker:
Hispanic Origin:
Spouse Full Name:
Spouse Maiden Name:
Mother's Full Name:
Mother's Maiden Name:
Father's Full Name:
 

Military Service
(If Applicable)
Service Branch:
Serial Number:
Place Enlisted:
Date Enlisted:
Place Discharged:
Date Discharged:
VA Claim or File #:
 
Funeral Preferences
Music Selections To Be Played: 1.
2.
3.
4.
Music Selections To Be Sung: 1.
2.
3.
4.
Will Supply CD or Tape
Favorite Bible Passages:
Favorite Literature Or Poems:
Favorite Flower(s):
Favorite Flower Color:
Final Disposition
Preference For Final Disposition Is:
Deed Holder:

Section:
Range:
Plot:
Other:
Obituary Information
Survivor Name
Relationship
City
State
Person(s) to Finalize Arrangements At Time Of Death
Name:
Relationship to Pre-Deceased:
Address:
Daytime Phone:
Evening Phone:
Second Contact
Name:
Relationship to Pre-Deceased:
Address:
Daytime Phone:
Evening Phone:
Other Information, Special Instructions, Other People To Contact