Information for the person the plan is for Name* First Middle Last This is the part of the form where we need your first, middle, and last name.Phone*Email* Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Family Information Marital Status*MarriedSingleWidowedPlease choose one of the following.Name of Spouse:* First Middle Last Spouse Maiden Name:If deceased, date of death: Date Format: MM slash DD slash YYYY Father's Name: First Middle Last Father's Birth Place:Mother's Birth Place:Siblings (Living):Siblings (Deceased):Children (Living):Children (Deceased):Grandchildren (Living):Grandchildren (Deceased):Great Grandchildren (Living):Great Grandchildren (Deceased):Education/WorkHighest Level of Education:Occupation:Industry:Military ServiceMilitary ServiceYesNoBranch of Service:Years Served:Funeral Home will need to have a copy of the discharge or separation papers form DD-214.Burial or Cremation?BurialCremationFuneral Options:Funeral service at funeral home.Funeral service at:I do not wish to have a funeral service.Funeral service at funeral home.Funeral service at:I do not wish to have a funeral service.Disposition Options:Ground Interment (burial)Mausoleum Entombment (above ground burial)Columbarium (for cremation urns)Ashes returned to familyPlease list any musical selections you would like to include in your services.Please list any poems, religious texts, or readings you would like to be read at your services.Please list any interests or hobbies you would like to include into your services.Please list any special themes you would like to include into your services.Is there a special story, personal thank you, or message of hope you would like to be read during your services?
