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Personal Information:
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First Name:
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Middle Name:
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Last Name:
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Phone:
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Email:
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Address:
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City:
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State:
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Zip Code:
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Date of Birth:
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Place of Birth:
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(City & State or County & State) |
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Marital Status:
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Spouse's Name:
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Maiden name & full name of wife or husband's full name |
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Social Security #:
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Father's Full Name:
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Mother's Full Name:
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Person who will be in
charge of my funeral
arrangements
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Name:
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Address:
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City:
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State:
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Zip Code:
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Phone Number:
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Military Information:
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Branch of Service:
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Description of Service:
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(Wars fought in, medals earned, military campaigns) |
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Veteran's Service Number:
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Rank:
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Location of Discharge Papers:
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Do you wish to have a military graveside service?:
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Work/Education:
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Education (0-12):
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College (1-5+):
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Occupation:
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Business:
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Company:
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Family Members:
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Spouse:
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(Name, Address & phone number) |
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Daughters:
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(Name, Hometown & phone number) |
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Sons:
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(Name, Hometown & phone number) |
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Number of Grandchildren:
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Sisters:
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(Name, Hometown & phone number) |
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Brothers:
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(Name, Hometown & phone number) |
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Other Relatives:
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(Name, Hometown & phone number) |
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Those who have
preceded you in death:
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(Name and Relation) |
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My Funeral Service Preferences:
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Church Membership:
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Place of Service:
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(Funeral Home, Church, Graveside or other) |
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Clergy:
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(Name, Address & phone number) |
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Type of Disposition:
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Cemetery Property Owned?
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Name of Cemetery:
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(Include: Location of Cemetery, City & State) |
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Cemetery Preference:
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(If property not owned, include location
of cemetery, city & state) |
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Music Selections:
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(Organ or piano background, live vocal, or recorded music) |
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If live vocal, include the vocalist, phone number
and list of songs. |
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Pallbearers and
Honorary Pallbearers:
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Include pallbearers hometown,
home phone number and
bearer type designation)
(A = Active Bearer,
H = Honorary Bearer)
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Lodge, Society,
Fraternal Organization:
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(List involvement and if you would like an honor guard) |
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Flowers:
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Memorial Contributions/Donations:
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Obituary Information:
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List education and place of schooling, wedding date and place, work history and places lived and worked, clubs, lodges, hobbies, significant accomplishments, boards, committees, community and church involvement, etc.
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Do you wish to have
memorial photos displayed?
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Any information or
special instructions not
previously listed:
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Please check as many of the following as apply:
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Please contact me so that I may select my casket and vault in advance |
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Please forward me a copy of my information for my records. |
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Please contact me if any of my submitted information needs clarification. |
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File my information for future reference at Mann and Greenwell, but please do not contact me. |
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I would like to discuss my pre-payment options with no obligation, please contact me. |
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