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:

1. Choose one of the submit buttons at the end of the form
2. Print the completed form and place it with your important papers
Information about person completing the form:
First Name: * Today's Date: *
Middle Name: I Am Planning For: *
Last Name: * Email:
Daytime Phone: * (555-555-5555)  
Evening Phone: (555-555-5555) Fax: (555-555-5555)
* required fields must be filled out
Personal Information about person planning for
Be sure to use their Full Legal Name
First Name: * Sex: *
Middle Name: Marital Status : *
Last Name: * Education Level: *
Date of Birth: * (mm/dd/yyyy) Place of Birth: *
Street Address: *
Mailing Address: *
City: * County: *
State: * Zip Code: *
Length of Stay In County: * Is Home Address Inside
City Limits: *
Smoker? * Hispanic Origin ? *
Spouse's Full Name: Spouse's Maiden Name:
Mother's Name: Mother's Maiden Name:
Father's Name:  
* required fields must be filled out
Military Service
Service Branch: Serial Number:
Place Enlisted: Date Enlisted:
Place Discharged: Date Discharged:
VA Claim or File:  
Funeral Preferences
I Prefer The Funeral Service To Be: *
Place Of Service: * Name Of Cemetery : *
City:
*		 State:
*
Religious Denomination: Church Affiliation:
Clergy Type:
Clergy Name:
Grave or Niche Location: * I Prefer: *
Viewing For Family: * Viewing For Friends: *
For the family selecting cremation, what disposition of the remains would you prefer:
*
Option: *
Funeral Preferences
Musical Selections To Be Played:
Musical Selections To Be Sung:
Will Supply CD/Tape
Favorite Bible Passage:
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
First Conact:
Name: * Address: *
Daytime Phone: * (555-555-5555) Evening Phone: (555-555-5555)
Relationship: *  
Second Contact:
Name: Address:
Daytime Phone: (555-555-5555) Evening Phone: (555-555-5555)
Relationship:  
Other Information / Special Instructions / Other People To Contact:
Please Call Me
Keep Information On File