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Dear sir or madam,
     These times are always tough.  There is a lot of information that we will need for the funeral, completion of the death certificate, obituary and other forms.  You may fill out this form completely, or in part as this page is designed to assist you in compiling this information.  If you have any questions,  feel free to call, email, or wait until the arrangement conference at the funeral home.  If you do not want to complete this form online, click here to open a printable version of this page (Note: requires Adobe viewer, click here to get it if you do not have it already.)

Please note that this form is for families wishing to fill out information for someone who has passed away.  If you are wishing to pre-arrange a funeral, please click here to go the the Pre-Arrangement page.

Information about the Deceased:

What is the deceased's full name?
First: 
Middle: 
Last: 
Nickname: 

What is his/her Social Security Number?
  ex: 123-45-6789

 What is his/her date of birth? 

What is his/her age?

What is his/her address of residence?
Street: 
City:   
State: 
Zip: 

Is the residence inside the city limits? Yes     No

What is the closest town to the place of birth? 

What is his/her marital status? 

If married, widowed, or married, but separated, what is the spouses full name?
First: 
Middle: 
Maiden (if applicable): 
Last: 

What was his/her father's full name?
First: 
Middle: 
Last: 

If living, what is the town of residence?  

What was his/her mother's full name?
First: 
Middle:
Maiden: 
Last: 
If living, what is the town of residence? 

How far did  he/she go through school? 

Was he/she a veteran?  Yes     No
     If yes, What branch?
     What war (if applicable)? 

Was he/she a member of a church or of a particular faith? 
    

What industry did he/she work in? 
     What was his/her job in this industry? 

 Survivor Information:

Keep in mind that the people to be listed in this section are survivors.  Anyone who preceded your loved one in death will be listed later on this form.

Sons: 
Daughters: 
Grandchildren: 
Great Grandchildren: 
Brothers: 
Sisters: 
Other Survivors: 
Preceded in death by: 

Information about the receiving of friends and funeral:

When would you like to have the receiving of friends? 
Where would you like to have the receiving? 

What day would you like to have the funeral? 
What time? 
Where would you like to have it? 
Who would you like to speak at the funeral?


Does he/she already have a grave space?  Yes     No
     If yes, where? 
Who will be singing at the funeral?

Who would you like to serve as pallbearers (normally 6 - 8 people)?

Would you like to do memorials in lieu of flowers?  Yes     No
     If yes, to whom? 

Additional questions you may have:

 

What is the telephone number at which the next of kin can be reached?
    

Is there an email address where information can be sent if necessary?
     Yes     No          If yes,