Wright & Young Funeral Home, Inc.
Arrangement Record - FL
1.DECEDENT'S NAME(First, Middle, Last, Suffix)
First Name
Middle Name
Last Name
Suffix
Case #
Burial Permit #
2. SEX
3. DATE OF BIRTH(Month, Day, Year)
4a. AGE - Last Birthday(Years)
4b. UNDER 1 YEAR (months)
4b. UNDER 1 YEAR (days)
4c. UNDER 1 DAY (Hours)
4c. UNDER 1 DAY (Minutes)
5. DATE OF DEATH (Month, Day, Year)
6. SOCIAL SECURITY NUMBER
7. BIRTHPLACE (City and State or Foreign Country)
8. COUNTRY OF DEATH
9. PLACE OF DEATH
(Check only one)
HOSPITAL:
Inpatient
Emergency Room/Outpatient
Dead on Arrival
NON-HOSPITAL:
Hospice facility
Nursing Home/Long Term Care Facility
Decedent's Home
Other (Specify)
10. FACILITY NAME(If not institution, give street address)
11a. CITY, TOWN, OR LOCATION OF DEATH
11b. INSIDE CITY LIMITS?
Yes
No
12. MARITAL STATUS(Specify)
Married
Married, but Separated
Widowed
Divorced
Never Marrried
13. SURVIVING SPOUSE'S NAME (If wife, give maiden name)
Marriage Date
Marriage place
14a. RESIDENCE - STATE
14b. COUNTY
14c. CITY, TOWN, OR LOCATION
14d. STREET ADDRESS
14e. APT. NO
14f. ZIP CODE
14g. INSIDE CITY LIMITS?
Yes
No
Phone
Email
15a. DECEDENT'S USUAL OCCUPATION(Indicate type of work done during most of working life.)
15b. KIND OF BUSINESS/INDUSTRY
Employed By
Yrs
Location
16. DECEDENT'S RACE (Specify the race/races to indicate what decedent considered himself/herself to be. More than one race may be specified.)
White
Black or African American
American Indian or Alaskan Native(Specify tribe)
Asian Indian
Chinese
Filipino
Japanese
Koeran
Vietnamese
Other Asian(Specify)
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Isl.(Specify)
Other (Specify)
17. DECEDENT OF HISPANIC OR HAITIAN ORIGIN?(Specify if decedent was of Hispanic or Haitian Origin.)
Yes(If Yes, specify)
No
Mexican
Puerto Rican
Cuban
Central/South American
Other Hispanic(Specify)
18. DECEDENT'S EDUCATION(Specify the decedent's highest degree or level of school completed at time of death.)
8th or less
High school but no diploma
High school diploma or GED
College but no degree
College degree(Specify)
Associate
Bachelor's
Master's
Doctorate
19. WAS DECEDENT EVER IN U.S. ARMED FORCES?
Yes
No
20. FATHER'S NAME (First, Middle, Last, Suffix)
21. MOTHER'S NAME (First, Middle, Last, Suffix)
22a. INFORMANT'S NAME
22b. RELATIONSHIP TO DECEDENT
23a. INFORMANT'S MAILING - STATE
23b. CITY OR TOWN
23c. STREET ADDRESS
23d. ZIP CODE
24a. PLACE OF DISPOSITION(Name of cemetery, crematory, or other place)
25a. LOCATION - STATE
25b. LOCATION - CITY OR TOWN
26a. METHOD OF DISPOSITION
Burial
Entombment
Cremation
Donation
Removal from State
Other (Specify)
26b. IF CREMATION, DONATION OR BURIAL AT SEA, WAS MEDICAL EXAMINER APPROVAL GRANTED?
Yes
No
Services
Place
Date
Time
Minister
Minister's Church
Special Music
Organist
Other Service Type
Other Service Date
Other Service Time
Other Service Place
Family Car Address
Time Wanted
Phone
Viewings
Viewing(Place, Date, Time, etc)
Family Viewing(Place, Date, Time, etc)
Memorials To:
Submit
Should be Empty: