I. Biographical Information
Full Name:
Date of Death:
Address1
Address2:
City Name:
State:
Zip Code:
Telephone Number:
Email Address:
Date of Birth:
City of Birth:
State of Birth:
Highest Education Level: - - Elementary Secondary College/University
Please select Grade/Years of Education completed: -- 0 1 2 3 4 5 6 7 8 9 10 11 12
Residence History:
Father's Name:
Father's City of Residence:
Mother's Name:
Mother's City of Residence:
Mother's Maiden Name:
Spouse's Name:
Spouse's Maiden Name:
Survivors' Names and Cities of Residence
Relatives Who Have Preceded In Death
Occupation:
Business Type:
Company Name:
Church Membership:
Lodge or Union Name:
II. Military Record
Veteran: Yes No
Branch of Service: None Army Navy Air Force Marines Coast Guard National Guard
Serial Number:
Date Enlisted:
Date of Discharge:
Rank at Discharge:
Location of a Copy of Discharge (DD214):
Time of Military Service: Not a Veteran Peacetime World War I World War II Korean War Vietnam War Persian Gulf War
Military Honors at Graveside: Not a Veteran Yes No
Flag Preference for Service: None Drape Casket with Flag Folded Flag on Casket
III. Service Preferences
Type of Service: Chapel Service Church Graveside None
Visitation Hours: Day Night None
Casket: Open for service Closed for service No public viewing
Person in Charge of Arrangements:
Officiating Clergy:
Pallbearers:
Flower Preference:
Music Selection:
Jewelry: No jewelry Give to family Leave jewelry on
Glasses: No glasses Donate to Lions Club Leave on Give to family
Casket Preference: Select a Casket Bronze Copper Stainless Steel Steel (sealing) Minimum Metal Mahogany Walnut Cherry Maple Poplar Pine Fiberboard / Veneer
Disposition: Select Disposition Ground burial Mausoleum Cremation
Outer Container Preference: (for ground burial) Select a Burial Container Bronze Triune Copper Triune Cameo Rose SST Triune Veteran Venetian Continental Monticello Minimum Grave Liner
Cemetery Name:
Cemetery Location:
The cemetery property is in the name of:
Miscellaneous Notes and Instructions:
Please select one of the options below:
