Funeral Arrangement Worksheet

Pre-Arrangement Worksheet

Fill out the form carefully and verify all information is correct.
Your Information
Name*

First NameMiddle NameLast NameSuffix
Nickname
Date of Birth

MonthDayYear
Age
Sex
Social Security Number
Marital Status
Birthplace
State or Country (If not USA)
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Residence Inside City Limits?

YesNo
US Citizen?

YesNo
If Not a US Citizen, What Country?
Hispanic Origin?

YesNo
Race
i.e. White, Black, Asian or Pacific Islander, American Indian, Latino, Puerto Rican, Cuban etc.
Served in Armed Forces?

YesNo
DD214 Discharge Papers Available?

YesNo
Branch of Service (If Applicable)
(i.e. Army, Navy, Air Force, Marines, Coast Guard)
Level of Education
Occupation
Business or Industry
Father's Full Name

First NameMiddle NameLast NameSuffix
Mother's Full Name

First NameMiddle NameMaiden Last NameSuffix
Next of Kin's Email Address
example@example.com
Next of Kin's Phone Number
Please enter a valid phone number.
Service Information

Please fill in only the sections that apply. If undecided, leave blank.
Type of Disposition

BurialCremation
If Burial, Select Services (If Undecided, Leave Blank)

Visitation ServiceFuneral ServiceGraveside Service
If Cremation, Select Services (If Undecided, Leave Blank)

Direct Cremation (No Services)Visitation ServiceMemorial ServiceFuneral ServiceGraveside Service
Obituary Information
Would you like to have an obituary appear on our website or in a newspaper publication?

YesNo
Will There Be a Photo Included in the Paper or on Our Website?

YesNo
Should be Empty:

Pre-Arrangement Worksheet

Your Information

Service Information

Obituary Information