Funeral Insurance
.........................................................................................................................................................................................

Click here for printable PDF version which can be filled out by pen. PDF is Viewable through the Adobe Acrobat Reader, if you do not have the reader click here to install it.
Please select a location you would like to submit
the form below to from the drop down list:
Personal Information
First Name:
Middle Name:
Last Name:
Date of Birth:
Birthplace:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Email Address:
 
Father's Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:
 
Mother's Maiden Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:
 
Where were you raised and what schools did you attend?
 
Maiden Name of Spouse:
Date of Marriage:
Place:
If deceased, date of death:
 
Where have you lived during your adult life?
 
Name of children & their spouses, and their addresses
Child#1 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#2 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#3 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#4 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
Child#5 Name:

Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:
 
Current Number of Grandchildren:
Current Number of Great Grandchildren:
 
Names of surviving brothers & sisters and their addresses
Sibling#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Sibling#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
 
Preceded in death by
 
Occupation. Give the type of work done most of working life, even if retired.
Name of Employer:
If Retired, Date of Retirement:
Total years spent in your occupation:
 
Church affiliation & activities:
List membership in fraternal, civic, or professional organizations:
 
Did you serve in the military? Yes No
If yes, what branch:
List membership in fraternal, civic, or professional organizations:
 
Special events in my life not listed previously:
 
FUNERAL INSTRUCTIONS
Place of Service:
Minister:
Minister:
Music Selections:
Organist:
Singer(s):
Singer#1:
Singer#2:
Singer#3:
Singer#4:
Singer#5:
Pallbearers:
Pallbearer#1:
Pallbearer#2:
Pallbearer#3:
Pallbearer#4:
Pallbearer#5:
Pallbearer#6:
Pallbearer#7:
Pallbearer#8:
Favorite Bible Selections:
Special Services (Military or Lodge)
 
Cemetery Information
Name of Cemetery:
Location City:
Lot is in the name of:
Section:
Lot:
Grave Space:
 
Casket and Burial Preferences
Casket:
Metal:
Wood:
Exterior Color:
Interior:
Burial Vault:
 
Authorized Persons to Arrange Final Details
Person#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Person#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
 
 
My Special Wishes
Clothing, jewelry, etc.