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On-Line Pre-Arrangement
 
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

Information about person completing the form:
First: Today's Date:
Middle: I am planning for my:
Last: E-mail:
Daytime Phone: Evening Phone:
Fax (If available):
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: 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:
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:
Grave or Niche Location:
Religious Denomination:
Church Affiliation:
Name:
Viewing For Family:
Viewing For Friends:
I Prefer
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 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:
Address:
Daytime Phone: Evening Phone:
Second Contact
Name:
Relationship:
Address:
Daytime Phone: Evening Phone:
Other Information | Special Instructions | Other People To Contact
Please Call Me
 Keep Information On File
 
     
 
     

Pre-Need Center | Being Prepared | Pre-Arrangement FAQ's
Facts & Benefits | When Death Occurs | Online Pre-Arrangement

  

John F. Pfleger Funeral Home, Inc.
115 Tindall Road, P.O. Box 219, Middletown, NJ 07748
Tel: (732) 671-1326 Email: pflegerfh@aol.com
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This page was last edited Thursday, February 14, 2008