I. Biographical Information
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First/Middle/Last Name: |
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Gender: |
Male Female |
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Address1: |
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Address2: |
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City: |
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State: |
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Zip Code: |
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Telephone Number: |
(xxx-xxx-xxxx) |
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Email Address: |
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Date of Birth: |
(month/day/year) |
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City of Birth: |
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State of Birth: |
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Highest Education Level: |
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Please select Grade/Years of Education completed: |
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Social Security Number: |
(xxx-xx-xxxx) |
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Residence Since: |
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Moved to Residence from: |
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Primary Care Physician: |
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Father's Name: |
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Mother's Name: |
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Mother's Maiden Name: |
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Marital Status: |
Never married Married Divorced Widowed |
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Spouse's Name: |
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Spouse's Maiden Name: |
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If Deceased, year of death |
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Survivors' Names and Cities of Residence (Parents, Children, Siblings) |
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Relatives Who Have Preceded You In Death |
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Number of Grandchildren |
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Number of Great-Grandchildren |
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Your Occupation: |
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Business Type: |
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Employer: |
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Religion: |
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Church Membership: |
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Lodge or Union Name: |
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Activities and/or Hobbies |
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II. Military Record
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Veteran: |
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Branch of Service: |
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Service Number: |
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Date Enlisted: |
(month/day/year) |
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Date of Discharge: |
(month/day/year) |
Rank at Discharge:
Note: You will need to provide a copy of the Discharge (DD214) |
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War Veteran: |
Yes No |
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If so, what war? |
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Military Honors at Graveside: |
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Flag Preference for Service: |
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III. Service Preferences
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I request: |
Burial Cremation |
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If cremation, will the ashes be: |
Buried Scattered Returned to Family |
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If Burial, what cemetery? |
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Cemetery City: |
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I would prefer: |
A Traditional Service A Graveside Service A Memorial Service No Service |
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If you selected a traditional or memorial service, please indicate the preferred location. |
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Would you like public visitation? |
Yes No |
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Would you like a reception at our 104 Limerock facility or another facility? |
Yes, at 104 Limerock Yes, at another facility No |
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Person in Charge of Arrangements: |
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Name of the Clergy / Officiant: |
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Music Selection: |
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Jewelry: |
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Glasses: |
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Miscellaneous Notes and Instructions:
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Please select one of the options below:
Please send me information on funeral planning
Please contact me to schedule an appointment
Please place my information on file
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