RECORD OF FUNERAL

VITAL STATISTICS

Full Name:

Birthplace:

Date of Birth:

Marital Status:

Name of Spouse:

Date of Marriage:

Fathers Name:

Mothers Maiden Name:

Social Security Number:

Occupation:

Business:

    
FUNERAL SERVICE REQUESTS
Name of Mortuary: City and State:

Place of Service:

 Church Denomination:
Lodge or Union: Persons to be in charge of final arrangements:
Relationship: Address:
    Phone:
MILITARY RECORD

Name of War:

Serial No.

Date & Place of Induction

Date & Place of Discharge

Branch of Service:

Rank at Discharge:
SPECIAL INSTRUCTIONS
Flower Preference: Music Preference:
Casket Bearers: Jewerly
Glasses: Clothing:
Obituary: Others:
PERSONS TO BE NOTIFIED   INSURANCE INFORMATION
 
INTERMENT REQUESTS
I Prefer: Name of Cemetery:
City & State: I Have Reserved Facilities:
I have made a last will & testament: It is located at: