Pre-Need

All through our lives, we are constantly faced with making important decisions. These decisions might be about your employment, provisions for a good home for your family, planning for retirement, all with your family uppermost in your mind. Pre-planning your funeral arrangements is just another decision that people made with their families in mind, mostly to alleviate the burden at a crucial time in their lives. Also available is pre-payment, to guarantee the cost of a funeral at a later date. The following form is a questionnaire that will help to specify what your particular wishes are, plus, vital statistics are needed for newspaper notices and the filing of a certificate.

**Personal Information**
Name (First MI Last):
Marital Status:		Social_Security #:
Date of Birth:		Place Of Birth:
Address:
City:		State:
County:		Zip:
Phone:		E-mail:
Spouse's Name:		Spouse's Maiden Name:
Place of Marriage:		Date of Marriage:
Father's Name:		Mother's Name:
Mother's Maiden Name:

Person in Charge:
Address:
Phone:

**Work/Education History**
Education (0-12):		College 1-5+:
Occupation:
Business:		Company:

**Military Record**
Branch of Service:		Serial Number:
Date Enlisted:		Rank At Discharge:
Date Discharged:		Discharge On File At:
Copy of Discharge Papers: Yes No
Name Of Wars:
Do you want Honor Guard	Yes No

**Funeral Service Request**
Place Of Service:
Funeral Home:
Address:		Phone:
Place of Visitation:
Religious Denomination:
Place Of Worship:

Newspaper Information (Please list family members)

Children's Names:	Additional Children	City of Residence:	Children's Residence's
Brothers/Sisters:	Additional	City of Residence:	Additional
Number of Grandchildren:
Number of Great Grandchildren:
List any other significant relatives:

**Special Instructions**
Lodges and Organizations and Interests:
Jewelry:
Glasses:
Person in Charge of Final Arrangements:
Clothing Preference:	My own Other

**Disposition Request**
I Prefer:
Cemetery:
Address:		Phone:
Section:
I have made a last will and testament: Yes No
Location:

**Other Instructions**

Memorials/Donations To Charity

**Please select all that apply:**
Send information about pre-arrangement Contact me to set an appointment Please keep my information on file