Arrington Funeral Directors Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Have you pre-planned for your funeral and/or cemetery property?

YesNo

Have you ever been responsible for making funeral arrangements for a friend or for another member of your family at the time of their death?

YesNo

In the event of your death, who would be responsible for your arrangements?

SpouseChild(ren)Family MemberOther

Are your loved ones aware of your funeral preferences?

YesNo

Do you have up-to-date biographical information and accurate records that would help a loved one with your funeral planning?

YesNo

Are you aware of the options and benefits of guaranteed pre-paid funerals?

YesNo

Did you know that you can protect some of your assets by pre-paying funeral expenses before applying for Medicaid?

YesNo

Would it give you peace of mind if you could do your funeral planning in advance and know that your family would not have to make your arrangements themselves?

YesNo

Advanced Funeral Planning is something that... (Check all that apply)

you have talked about.you have considered.you would like to know more about.other family members have done.

All information will be kept strictly confidential and used only to help us identify areas to improve the service we provide to the families of our community.

This survey is part of a general distribution to an entire zip code. Delivery to a home where illness or recent bereavement exists is unintentional. If this survey was received in an earlier mailing and/or pre-arrangements have been made, please feel free to disregard this mailing.