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Statistical Information for the Deceased

Name:

Gender:

Female

Male

Race:

Date of Birth:

Place of Birth:

Date of Death:

City of Death

State of Death:

County of Death:

Location of Death:

Location Name and Address:

Social Security Number:

Education:

College:

Usual Occupation:

Kind of Business:

Company:

Marital Status:

Surviving Spouse:

Maiden Name (if wife):

Residence Address:

City/Town:

State:

Zip:

Inside City Limits?

County:

Length of Residence in County:

Father's Full Name:

Mother's Full Maiden Name:

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Type of Disposition

Disposition will be:

If Cremation, disposition of ashes?

Options:

Name of Cemetery (if applicable)

City/State:

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Veteran Information

Branch of Service:

Serial Number:

Date Enlisted:

Date Discharged:

Discharge on File at:

Is a copy of discharge papers available?

Honorable discharge?:

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Important Information

Name of Person In Charge:

Relationship to Deceased:

Full Address:

Phone:

Email:

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Funeral/Memorial Service Information

Preferred Place of Service:

Religious Denomination:

Is there Pre-Need Funeral insurance on decedent?:

If yes, please specify type:

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Special Instructions

Note: Use area below to indicate any additional information that may be helpful at this time. Other details regarding services, merchandise, flowers, financing, etc., will be discussed and finalized at the arrangement conference.

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Full Payment is due 48 hours before Service

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