Preplanning Form
Today's Date Name of Person (please include middle name or initial) Sex Male Female Education Level Race Hispanic Origin? Yes No If yes, specify Address City State Zip Where is the person now? Home Nursing Home Hospital Marital Status Married Divorced Widowed Never Married Date of Birth Place of Birth Social Security # Occupation (even if retired) Kind of Business/Industry Most Recent Spouse's Name Even if Divorced (Maiden Name if Wife) Father's Full Name State of Birth or Country if Not in US Mother's Full Maiden Name State of Birth or Country if Not in US Religion Church Choose One Burial Cremation Cremation then Burial of Ashes Donation Cemetery City Section Lot Grave Newspapers to Insert Obituary Veteran Yes No If yes, we will need a copy of the discharge papers Branch of Service Army Marines Air Force Navy Coast Guard Other Rank Years in Service Donations (Memorial Gifts) Relatives Living and Deceased - Please List Name and City in Which They Live Children Siblings Grandchildren Great Grandchilren Nieces & Nephews Aunts & Uncles Grandparents Parents Please list any interests, hobbies, memberships, special accomplishments, what is held most dearly and how person would wish to be memorialized Informant Name Relationship Address City State Zip Telephone Number Additional Comments