Pre-planning Information Form

This information form will be used for the Death Certificate and Obituary. The Social Security Number will be needed at the time of final arrangements.


	Full Name
	Current Residence Address
	City
	County
	State
	Zip
	Telephone

	Race
	Marital Status
	Spouse's Name
	Maiden Name
	Year of Death
	Birthplace
	Date of Birth
	Father's Name
	Mother's Maiden Name

	Years Completed in School
	Veteran
	Branch, Rank, Service Dates
	Usual Occupation
	Type of Industry
	Employer
	No. of years
	Year Retired

	Lived in this area since
	Moved from
	Religion
	Membership	Member Attended Non-Member
	Church or Synagogue
	City
	Clubs, Organizations, Awards
	Number of Certified Death Certificates
Next of Kin Information
	Name
	Relationship
	Address
	City
	State
	Zip
	Phone
I hereby request the following action be taken upon my death:
	I would prefer a Public Visitation or Viewing Yes No
	I would prefer a Private Visitation for only my Family Yes No
	I would prefer my services held at
	I would prefer as clergyman
	I request the following music

	I request Burial Entombment Cremation
	Name of Cemetery
	City & State
	Section Block Lot Grave #
	If cremation is chosen the cremains are to be:
	Scattered Buried Given to my family

	I would like Newspaper notices in
	The types of flowers I would like are
	As a veteran I would like military honors Yes No
	The Merchandise I would prefer
	Casket
	Vault
	Urn
	Keepsake Urns/Jewelry
	Memorial/Prayer Cards

T: (847) 234-0022
F: (847) 234-7959
email: info@wenbanfh.com

Pre-planning Information Form

Next of Kin Information

I hereby request the following action be taken upon my death:

The Merchandise I would prefer

I hereby request the following
action be taken upon my death: