This form is provided as a service to allow you to record funeral preferences for yourself or a loved one. Once you have filled in the information you may:

• Click the submit button at the end of the form and it will be sent to us.
• Print the completed form and mail it to the address at the bottom of this page for us to keep on file.
• Print the completed form and place it with your important papers.

Information about person completing the form:
Today's Date:	08-20-08	I am planning for:   self spouse mother father child friend
First Name:		M.I.   Last Name:
Daytime phone:		Evening phone:
Fax: (if available)		Email Address:

Personal Information about person planning for:
Be sure to use their full legal name.
First Name:
Middle Name:
Last Name:
Date of Birth:		Place of Birth:
Street Address:
City:		County:
Length of Stay in County:		Is Home Address Inside City Limits:	Yes No
Spouse's Full Name:		Spouse's Maiden Name:
Mother's Full Name:		Mother's Maiden Name:
Father's Full Name:

Military Service:
Service Branch:		Serial Number:
Location Enlisted:		Date Enlisted:
Location Discharged:		Date Discharged:
VA Claim or File #:

Funeral Preferences
	Place of Service:
	Name of Cemetery:
	City:
	State:
	Religous Denomination:
	Church Affiliation:
	Elder Priest Minister Clergyman Rabbi Reader Name:
	Viewing for Family:	Yes No
	Viewing for Friends:	Yes No
	I prefer:	Burial Cremation Other
	If cremation, what disposition of the remains would you prefer:
	Type of Service Option:	Traditional Burial Service Graveside Burial Service Immediate Burial Traditional Cremation Service Memorial Cremation Service Graveside Cremation Service Direct Cremation

Funeral Service Preferences
Musical Selections to be Played:	1. 2. 3. 4.
Musical Selections to be Sung:	1. 2. 3. 4.
Preference for Final Disposition Is:	Will supply CD/Tape

Obituary Information
Survivor Name	Relationship	City	State

Other Information   |   Special Instructions   |   Other People to Contact
Please Call Me Tell Me How To Pre-Pay Expenses Keep Information On File	Before submitting this form, please check it for correctness and completeness