Pre-planning Form

Information about the person completing this form

I am planning for

Last Name *

First Name *

Middle

Street Address

City

State

Zip

County

Phone *

E-mail

Information about the person you are planning for

Last Name

First Name

Middle

Gender

Marital Status

Date of Birth

Place of Birth

Spouse’s Full Name

Spouse’s Maiden Name

Place of Marriage

Date of Marriage

Mother’s Name

Mother’s Maiden Name

Father’s Name

Work and Education

Education (Primary)

College (1-5+)

Usual Occupation (most of life)

Kind of Business

Company

Military Records

Branch of Service

Serial Number

Date Enlisted

Rank at Discharge

Date Discharged

Discharge on file at

Copy of Discharge

Yes

Names of War/Conflict(s) Toured

Funeral or Memorial Service Preferences

Place of Service

Name of Funeral Home

Address

Phone

Place of Visitation

I prefer the funeral service to be

Viewing of Family

Yes

Viewing of Friends

Yes

Religious Denomination

Place of Worship

Lodge/Union

Person(s) to Finalize Arrangements at Time of Death

Full Name

Street Address

City

State

Zip

Phone

Special Instructions

Flower Preference

Music

Pallbearers (6)

Jewelry

Glasses

Clothing

Other

Disposition Options

I prefer

Cemetery

Address

Phone

Section

I have made a last will and testament

Other Information and Special Instructions

Please list any other instructions or information you would like us to have

Other Info

Memorials and Charities

Please list any Memorials or Donations to Charity that you would like

Memorials

Contact Options

Send information about pre-arrangement

Contact me to set an appointment

Please keep my information on file

815-626-6311

Preplanning

Information about the person completing this form

Information about the person you are planning for

Work and Education

Military Records

Funeral or Memorial Service Preferences

Person(s) to Finalize Arrangements at Time of Death

Special Instructions

Disposition Options

Other Information and Special Instructions

Memorials and Charities

Contact Options

Rock Falls

Sterling

Prophetstown

Milledgeville

Fulton