Information
For Prearrangement File
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Information On-Line Click Here
NAME:____________________________________________________________________
SEX:___________________
RACE:___________
DATE & PLACE OF BIRTH:
_________________________________________
RESIDENCE: STREET:
____________________________________________
LOCALITY:
CITY Of
__________________________ Village Of:
__________________
Town
Of _________________________
COUNTY:______________________________
STATE:_______________
ZIP CODE:___________________
PHONE: ______________
SERVED in US Armed Forces
YES_______ NO_______
If Yes: Date
of Enlistment ____________________ Date
Of Discharge _________
Service Number
____________________________________
EDUCATION (specify only highest grade
completed): _____________________________
SOCIAL SECURITY NUMBER
_____________________
MARITAL STATUS: (check
one) Never Married ______ Married or Seperated
_______
Widowed ________ Divorced ______
SURVIVING SPOUSE (if wife, provide
maiden name): ___________________________
USUAL OCCUPATION (do not enter retired):
__________________________________
KIND OF BUSINESS OR INDUSTRY EMPLOYED FOR:
______________________
NAME AND LOCALITY OF EMPLOYER:
___________________________________
IF RETIRED, WHEN?
_______________________________
NAME OF FATHER: _______________________________
BIRTHPLACE _____________________________________
MAIDEN NAME OF MOTHER:
_____________________
BIRTHPLACE: ____________________________________
WIFE'S MAIDEN NAME (if deceased)
_________________________________________
HUSBAND'S NAME (if deceased)
_____________________________________________
CHURCH AFFILIATION:
______________________________________________
CLERGY PERSON:
___________________________________________________
IF BURIAL IS THERE A CEMETERY PLOT ALREADY?
YES____ NO____
IF YES, Name and location of cemetery plot and
plot number (if available)
_____________________________________________________________________
IF NO, NAME AND LOCATION OF CEMETERY THAT SHOULD
BE SELECTED:
_____________________________________________________________________
SURVIVING RELATIVES (include city and
state of residence)
Father:
______________________________________________________________
Mother:
_____________________________________________________________
Husband or Wife
_______________________________________________________
Children (include spouses)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
Brothers and sisters (include
spouses):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________________
Number of grandchildren:
_________ Number of great-grandchildren:
___________
Names of deceased family members
to be listed:
______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
Organization & Club
memberships, Other details to be placed in newspaper
notices:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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