Pre-Planning Worksheet

Please provide the following contact information:

Full Name:
Street Address:
City:
State:
Zip/Postal Code:
Home Phone:
E-mail:

Relationship to Deceased:

Birthplace City/State/County

Birthdate

mm/dd/yy

Origin of Ancestors:

Race:

Citizenship:

Occupation:

Type of Business or Industry:

Education Level Attained:

Elementary/Secondary 0-12 College 1-4 Or College 5+

Father's Full Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:

Mother's Full Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:

Marital Status:

Married Never Married Widowed Divorced

Place of Marriage:

Spouse's Full Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:

Disposition:  Will you be?

Cremated Buried

Name of Crematory/Cemetary:
(cont.)
Street Address
City
State/Province
Zip/Postal Code
Country

Burial Lot Location Information

Grave Number:
Lot Number:
Section:
Addition:
Name on Burial Lot(s):
Is there a stone or monument there already?	Yes or No

Service Information

Location for Services:
City:
Minister:
Church Address:
Phone Number:

Location of Rosary:
Conducted by:
Altar Servers:
Military Services:
Fraternal Services:

Veteran's Burial

Were you ever in the Armed Forces?	Yes or No
If during war, which war?
Flag Presented to:
On Casket:	Folded or Draped
Location of Honorable Discharge Papers:

Date Enlisted:	mm/dd/yy
Place:
Serial No.:
Date Discharged:	mm/dd/yy
Place:
C-Number:

Organization:
Rank:
Serial No.:
Branch of Service:
Other Requests or Special Instructions

Family Information

Grandparents:

Please list family members in the order of their birth, from first to last:

Children:

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

Grandchildren:

Number of Grandchildren:
Number of GreatGrandchildren:
Number of Great-Great Grandchildren:
Preceded in Death by:
(continued) :

Brothers and Sisters:

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

 

Full Name:
Street Address
City
State/Province
Zip/Postal Code

This form will give us a basis for pre-planning your services.  Some additional information will be required and a Director will contact you to obtain any other necessary information and verify the information that you have submitted.

Thank you very much for your interest.