ࡱ>    !"#$%&'()*+,-./0123456789:;<=>?@ABRoot EntryZ O2jCCONTENTS CompObjVSPELLING __HS Grad. or GED __Some college, no deg. __Assoc. degree __Bach. Degree __Master s degree __Doctorate or prof. degree Social Security # Marital status _______________________ __ Never married __ Married __ Widowed __ Divorced __ Separated Spouse s name (include maiden name if wife) _______________________________________ if deceased, check here ___ Occupation Kind of industry Employer name and address _____________________________ ___________________________ _________________________________ _________________________________ Father s name Mother s name  include maiden name _____________________________________________ ______________________________________________ Residence (circle one) Street address ______________________________________________ City, Town, Village ____________________ County _________________________ State_________ Zip _________ If city or village, is it within limits? __yes __no Country if other than USA ______________________________ If no, specify town -__________________ Name of next of kin (or person who will be making your funeral arrangements) and mailing address (include zip) __________________________________________________________________________________________________ Relationship __________________________________________ Phone # (_______) ______________________ Obituary information Run the obituary or death notice in these newspapers ______________________________________________________ Length of time living here _______________________ Moved from where ___________________________________ CHNKWKS TEXTTEXTnSFDPPFDPPVFDPPFDPPXFDPCFDPCZSTSHSTSH\JSTSHSTSHJ\SYIDSYIDD]SGP SGP `]INK INK d]BTEPPLC h] BTECPLC ]FONTFONT]TOKNPLC "^TSTRSPLC v^PPRNTWNPR^kFRAMFRAM1~(TITLTITLY2DOP DOP ver married __ Married Recognizing that participating in these decisions will help my family in their grief, they can make these decisions - ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ I have kept my family in mind with these plans and this is what will be helpful to them as they go on in their grief and this is what will allow them to get support from my/their friends _____________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Name (First, Middle, Last) (maiden name if applicable) Sex Date of birth ____________________________________________________________ ____ _________________ Place of birth- City Vill. Town (Circle one) County State ______________________________________ __________________________ ________________ Hispanic origin ___ no ___ yes Race (circle one) __Mexican, Mex./Amer./Chicano White/Cauc. Black/Afri.Amer. Amer. Indian or Native Alaskan __ Puerto Rican __ Cuban Chinese Filipino Vietnamese Nat. Hawaiian __ Other (Span., Hispanic/Latino) Japanese Korean Guatemalan/Chamorro Specify ______________ Samoan Asian Indian Other Asian (specify) _______________ Other Pacific Islander ______________ Other (specify) ______________ Education __ 8th grade __9-12 (no diploma) Member of church ___________________________________________________________________________________ Civic organizations __________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Other personal information to be mentioned (hobbies, accomplishments, interests) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Include military service and employment information _____ yes ____ if my family wishes to ________________________________________________________________________________________________ ________________________________________________________________________________________________ Husband/wife _______________________________________ Number of years married _______________ Children ___________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Grandchildren ____________________________________________________ # of Great-grandchildren ____ ________________________________________________________________ # of Great-great-grandchildren ____ ________________________________________________________________ Other relatives _________________ ________________________________________________________________ ___________________________ ________________________________________________________________ Brothers/sisters ______________________________________________________________________________________ ___________________________________________________________________________________________________ Father ___ living ___ deceased Mother ___ living ___ deceased Service Information Public visiting hours ___ yes ___ no at the funeral home ___ at the church (if permissible) ___ other ________ No public visiting hours, but I d like my family to be able to have a private time ________ yes Service (place, minister) _________________________________________________________________________ Contributions __________________________________________________________________________________ ___________________________________________________________________________________________ Funeral info  music ____________________________________________________________________________ Scripture _______________________________________________________________________________ Other readings ___________________________________________________________________________ Speakers _______________________________________________________________________________ Pallbearers (if preference) _________________________________________________________________________ ____________________________________________________________________________________________ Clothing I want to be dressed in __________________________________________________________________________ Jewelry I want on for the services _______________________________________________________________________ to be removed and given to ____________________________________ relationship _____________________ Casket preference of type of wood or metal __________________________________________ color __________ Urn preference ________________________________________________________________________________ Burial vault preference __________________________________________________________________________ (include the model names and manufacturers if you chose the casket and/or urn and burial vault at the funeral home) Flowers - preference of kinds and colors __________________________________________________________ Funeral luncheon place _____________________________________________________________________________ ___ Burial Cemetery ___________________________________________________________________ ___ Cremation Grave Section __________________________ Lot ______ Range_______ Grave # ______ ___ Body donation City and State ______________________________________________________________ Grave marker ____ veterans marker (preference, if permissible, of flat bronze, flat granite, upright granite) ____ has already been purchased ____ needs to be purchased If cremated, do this with my ashes _______________________________________________________________________ I want to donate my body to science at the nearest medical school _______________________________________________ If for some reason my body is not accepted, please do this ____________________________________________________ __________________________________________________________________________________________________ I have signed an organ donor card on my driver s license or elsewhere _____ yes _____ no I have not signed an organ donor card but am interested in donating whatever can be used to help others. ____ yes Payment My funeral arrangements are paid ___ in full ___ partially ___ not at all. If paid in full or part, the money is deposited ____ through the funeral home ____ at this bank ____________________ in a burial account ____ with an insurance policy with this company _____________________ or with funds located ___________________________________________ Remember Whether it s printed in the obituary or said during the services, this is what I want people to know - ____________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ This is how I want to be remembered - ___________________________________________________________________ __________________________________________________________________________________________________ Funeral Preplanning Information My funeral home preference is - Name _______________________________________ Address ______________________________________ ______________________________________ Phone _______________________ I have given the funeral home a copy of this form ______. " if yes issible, of flat bronze, flat granite, upright granite) __QN"4 08\B4r: 8| N!!"#r$D% &&'t(F)**+x,H-..h/>0 11112~3L4556j7&889x:T;0<Z=4>? 4"*??@AbBJC&DDEFZG@H"IIJKKKJLLtMNNNNOjP2QRRRRRRSSXSS&TTTlUnU(2"'( 7 9n  " ""4" " "4" 4"6N"N p 4 P \vB4tP\*P 811KKKNNRRSSXSlUnU~t "!  "!$ "hC$."f  " " "$  " "6xTSH  Balloon TextxTSHDR(" $ 08  *$. 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