PERSONAL HISTORY

First Name

Middle Name

Last Name

Nickname

Maiden Name

Social Security #

Sex

Citizenship

Date of Death

Date of Birth

Place of Death

City

State/Country

Place of Birth

City

State/Country

Marital Status

Marriage Date and Location

Surviving Spouse or Significant Other

Occupation

How Long

Employed or retired from:	Business/Industry
	Years of Education

Residence Address

City

State state: ------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

County

Father's Full Name

Father's Birthplace

Mother's Full Name

Mother's Maiden Name

If a Veteran, branch of service

Discharge Rank/Date/Location

Obituary Information

Name should appear in the paper as

Newspapers to place obituary

Years as an area resident

Memberships: (Lodges, church, unions, etc.)

Donations to be made to

Number of grandchildren

great-grandchildren

great-great-grandchildren

Survivors: Name

Relationship

Address

FIRST THOUGHTS & PREFERENCES

Type of Disposition:      Burial       Mausoleum      Cremation      Scattering

Visitation/Friends Calling:      Yes       No

Location

Service Location:      Mortuary       Church       Chapel      Graveside      Other

Casket Selection          Open       Closed

Clothing

Glasses

Jewelry

Other

If cremation, urn selection

Plot Location

Cemetery

Address

City

State state: ------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Vault

INVOLVING FAMILY AND FRIENDS

Spoken words from family and friends are important to the grieving process. Note the people you want to hear from on that day:

Notes: Include any special readings (poems, scripture passages, etc.) you would like to include during the service.

Pallbearers

1.

Phone

2.

Phone

3.

Phone

4.

Phone

5.

Phone

6.

Phone

Honorary Pallbearers

OTHER DETAILS

Transportation Limousine option and list of family members who will riding.

Limo #1 1.

Limo #2 1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7.

7.

List of special requests and arrangements:

Pre-arranged set design

Participating fraternal, military or service organizations:

For military service, flag given to

Is a funeral WebCast arranged?

My notes:

SUGGESTED ORDER OF EVENTS

Life Celebrations arranger will coordinate the following with officiant:

Prelude: Music to be played during the time before the service starts.

Opening Comments/Welcome/Prayer by

Reading

Read by

Officiant remarks:

Eulogy/other speakers: The number of speakers is at the discretion of the family. A list of expected speakers helps the arranger coordinate the event. 1.

2.

3.

4.

Special music selection:

Postlude: Music you choose to be played at the end of service.

End of service invitation or directions to attendees:

ADD YOUR PERSONAL TOUCH...

Music to be performed by:      Organist*       Soloist* *Above to be arranged in advance with Life Celebrations counselor.

Instrumentalist(s) (Bugler, bagpiper, harpist, etc.)

CDs or favorite recorded music

Soloist invited by family

Flowers Flowers add to the ambiance of the setting. Casket and urn arrangements are traditionally reserved for the family.