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| Last name: |
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| Middle initial: |
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| Title: |
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| Sex: |
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| Race: |
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| Date Of Birth: |
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| Phone Number: |
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| House No. & Street: |
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| City: |
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| State: |
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| Zipcode: |
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| Town: |
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| Village: |
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| County: |
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| Served In US Armed Forces: |
Yes
No |
| If Yes: |
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| Date of Enlistment: |
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| Date of Discharge: |
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| Service Number: |
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Education:
(Specify only highest grade completed)
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| Social Security Number |
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Marital Status:
(check one) |
Never Married
Married or Seperated
Widowed
Divorced |
Surviving Spouse:
(If wife provide maiden name)
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Usual Occupation:
(do not enter retired) |
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| Kind of Business or Industry: |
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| Name and Locality of
Employer: |
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If Retired When:
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Name Of Father:
Birthplace: |
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Maiden Name Of Mother:
Birthplace: |
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Wife's Maiden Name:
(if deceased) |
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Husband's Name:
(if deceased)
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Church Affiliation:
Clergy Person:
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| If Burial Is There A Cemetary
Plot Alredy: |
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| If YES, Name and location of
cemetary plot and number if available. |
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If NO, Name and Location of
Cemetary That Should Be Selected
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Surviving Relatives:
(include city and state of residence)
Father:
Mother:
Husband or Wife: |
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Children::(include spouses)
Example:
Daughter - Mary E. Brown - Daniel - Buffalo NY
Son - James W. Smith - Helen -Syracuse NY |
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Brothers And Sisters:
(Include Spouses)
Example:
Brother-James T Water - Susan -Rochester NY
Sister - Phyllis T. Green - Walter - Albany NY |
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| Number of Grandchildren |
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| Number of
Great-grandchildren: |
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| Organization & Club
memberships, Other details to be placed in newspaper notices: |
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