|
Your E-mail:
|
|
VITAL STATISTICS RECORD
|
|
For the arrangements of (Last, First, Middle, Maiden):
|
|
|
Address:
|
|
|
City, State, Zip Code:
|
|
|
Residence in the city limits?
|
Yes
No
|
|
Formerly of (If Applicable):
|
|
|
Sex?
|
Male
Female
|
|
Date of birth:
|
|
|
Age:
|
|
|
Birthplace (City, County, State):
|
|
|
Social Security Number:
|
|
|
Full name of father:
|
|
|
Full / Maiden name of mother:
|
|
|
Marital Status:
|
|
|
Full / Maiden name of spouse:
|
|
|
Military Service (And if so, DD 214):
|
|
|
Occupation:
|
|
|
Employer:
|
|
|
How long?
|
|
|
Type of industry / business:
|
|
|
Church affiliation:
|
|
|
Civic involvement / memberships (including other):
|
|
SURVIVORS
|
|
Spouse (including city of residence):
|
|
|
Children (inlcuding in-laws and city of residence):
|
|
|
Brothers:
|
|
|
Sisters:
|
|
|
Parents (including city of residence):
|
|
|
Grandparents (if living):
|
|
|
Grandchildren (names including city of residence or total number):
|
|
|
# of great-grandchildren:
|
|
|
# of great-great-grandchildren:
|
|
FUNERAL INSTRUCTIONS
|
|
Place of funeral:
|
|
|
Officiating minister(s):
|
|
|
Place of interment ( name, city, state, zip, county):
|
|
|
Musical selection(s):
|
|
|
Vocalist(s):
|
|
|
Pianist(s) / Organist(s):
|
|
|
Visitation hour(s) and instructions:
|
|
|
Procession:
|
|
|
Flag?
|
Yes: Used as blanket.
Yes: Folded and placed inside casket.
Yes: Other
No
|
|
Hairdresser:
|
|
|
Pallbearers:
|
|
|
Other information / instructions:
|
|
|
Newspapers:
|
|
|
Memorials:
|
|
CONTACT INFORMATION
|
(other than the person in this arrangement)
|
|
Your name, relationship, address, city, state, zip code, home and other telephone number:
|
|
|
Name, relationship, address, city, state, zip code, home and other telephone number:
|
|
|
Name, relationship, address, city, state, zip code, home and other telephone number:
|
|
|
Name, relationship, address, city, state, zip code, home and other telephone number:
|
|
