In this booklet, you will find recorded information on decisions that I have made in advance to help you during this time. If you will give this booklet to my funeral director, everything can be conducted in accordance with my written wishes. I believe that this effort will minimize the emotional strain that you are in at this time. In this booklet, you will find vital statistics, estate information, funeral or cremation arrangements and other important information. I hope this, in someway, relieves you from the anxiety and burden of making these decisions at a very difficult time.

1.
To My Loved Ones
In
this
booklet,
you
will
find
recorded
information
on
decisions
that
I
have
made
in
advance
to
help
you
during
this
time.
If
you
will
give
this
booklet
to
my
funeral
director,
everything
can
be
conducted
in
accordance
with
my
written
wishes.
I
believe
that
this
effort
will
minimize
the
emotional
strain
that
you
are
in
at
this
time.
In
this
booklet,
you
will
find
vital
statistics,
estate
information,
funeral
or
cremation
arrangements
and
other
important
information.
I
hope
this,
in
someway,
relieves
you
from
the
anxiety
and
burden
of
making
these
decisions
at
a
very
difficult
time.
Sincerely,
By:
____________________________________________
Date:
__________________________________________
Personal Information
Full
Name:
____________________________________________________________________________________
Sex:
_______________
Social
Security
Number:
____________________________________________
Date
of
Birth:
____________________________________
Birthplace:
City:
________________________________
State:
________
Race:
_______________
Usual
Occupation:
___________________________________________________________________________
Kind
of
Business/Industry:
_________________________________________________________________
Physical
Address:
____________________________________________________________________________
City:
_____________________________________
State:
_________
Country:
_________________
Inside
City
Limits:
Yes
_____
No
_____
Marital
Status:
_______________________________________________________________________________

2.
Surviving
Spouse
Name
(If
wife,
give
maiden
name):
__________________________________________________
Highest
grade
of
education
completed
(including
college):
________________________________________
Father’s
Name:
______________________________________________________________________________
Mother’s
Name
(Include
maiden
name):
_______________________________________________________
If
burial,
name
of
cemetery:
________________________________________________________________
Location:
_____________________________________________________________________________________
Contact
Person
Completing
Arrangements:
_______________________________________________
Their
Address:
_______________________________________________________________________________
Their
Phone
#:
_______________________________________________________________________________
Medical Information
Medical
information
can
have
many
important
uses
for
your
spouse,
children
and
grandchildren.
Physicians
often
ask
for
medical
information
from
family
members.
Medical
Insurance
Company
Name:
_______________________________________________________
1. Identification
#:
_____________________________________________________________________
2.
Group
#:
_____________________
Phone
#:
_____________________________________
3. Member
Name:
______________________________________________________________________
My
Physician:
__________________________________
Phone
#:
_____________________________
Address:
______________________________________________________________________________________
Medical
History
(Please
list
any
serious
or
chronic
medical
problems):
_______________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Medications
I’m
allergic
to:
_________________________________________________________________

3.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Living
Will:
Yes
_____
No
_____
Location:
_____________________________________________________________________________________
Remarks:
_____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
I
am
an
Organ
Donor:
Yes
_____
No
_____
Remarks:
_____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Obituary Information
If
you
wish
to
run
an
obituary,
you
may
use
the
following
form
with
information
to
assist
the
funeral
home
with
the
obituary.
Name:
_________________________________________________________________________________________
Length
of
time
living
in
your
present
city/state:
__________________________________________
Previously
from:
_____________________________________________________________________________
Religion:
______________________________________________________________________________________
Church:
_______________________________________________________________________________________
Preceded
in
death
by
the
following
relatives:
_____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Surviving
Relatives:
_________________________________________________________________________

4.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Use
the
form
below
to
list
any
achievements
and
accomplishments
you
are
proud
of.
Childhood:
___________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Early
Adulthood:
____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Family
Moments:
____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Career:
________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Civic
Involvements:
_________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Other
Achievements:
________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5.
Funeral Home Information
Funeral
Home/Crematorium:
______________________________________________________________
Place
of
Service:
_____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Religious
Affiliation:
________________________
Location:
__________________________________
Clergyman/Speaker:
________________________________________________________________________
Other
Participants
(fraternal,
military,
etc…):
__________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Wake/Rosary
Service:
Yes
_____
No
_____
Officiator:
________________________________
Visitation/Viewing:
Yes
_____
No
_____
Flag
Presented
To
(if
applicable):
_____________________________________________________________
Clothing
Choice:
_____________________________________________________________________________
Personal
Items:
Jewelry
_______________
Remains
On
_____
Give
to:
______________________________________
Eyeglasses
________________
Remains
On
_____
Give
to:
_________________________________
Other
_______________
Remains
On
_____
Give
to:
________________________________________
Floral
Choice:
________________________________________________________________________________
Donations
may
be
made
to:
_________________________________________________________________
Music
Preferred:
_____________________________________________________________________________
Eulogy
By:
________________________________________________
Eulogy
Notes:
________________

6.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Open
Casket:
Yes
_____
No
_____
Type
of
casket
selected:
___________________________________________
$
_____________________
Color:
____________________________________
Interior
Color:
_________________________________
Type
of
urn
selected
if
cremation:
_________________________________________________________
Location
of
Pre-­‐Need
Contract:
_____________________________________________________________
Suggested
Pallbearers
with
Phone
#’s:
____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Honorary
Pallbearers
with
Phone
#’s:
_____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Additional
Remarks/Special
Instructions,
etc.:
___________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Cemetery Information
Cemetery:
____________________________________________________________________________________
Address:
____________________________________________________
Phone
#:
____________________
Type
of
Plot:
Family
_____
Companion
______
Individual
_____
Type
of
Property:
Mausoleum
_____
Ground
Burial
_____
Cremation
Gardens
_____
Description:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7.
Location
of
Deed:
____________________________________________________________________________
Type
of
Vault:
________________________________________________________________________________
Type
of
Memorial:
Upright
Monument
_____
Bronze
Plaque
_____
Granite
Plaque
_____
Other:
_________________________________________________________________________________________
Inscription:
___________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Other
Images,
Emblems,
etc.:
_______________________________________________________________
If
Cremation,
what
type
of
final
arrangements?
___________________________________________
Burial
______
Niche
_____
Scattering
Garden
_____
Cremation
Garden
_____
Other:
_________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Plaque
Inscription:
__________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Additional
Remarks/Special
Instructions,
etc.:
___________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
People to Notify
Name
Relationship
Phone
#
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Organizations to Notify
Name
of
Organization
Contact
Person
Phone
#
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Social Security
The
loss
of
the
family
wage
earner
can
be
devastating
to
the
survivors.
The
social
security
office
offers
a
variety
of
booklets
concerning
survivor
benefits.
Of
course,
the
information
provided
does
not
contain
all
provisions
of
the
law.
Each
case
may
be
different
and
you
would
need
to
contact
Social
Security
pertaining
to
your
individual
needs.
You
can
speak
to
a
service
representative
between
7a.m.
and
7p.m.
on
business
days.
Remember
to
have
your
social
security
number
ready.
Internet
Website:
www.socialsecurity.gov
Toll
Free
Number:
1-­‐800-­‐772-­‐1213
TTY
Number:
1-­‐800-­‐325-­‐0778
When
someone
who
has
worked
and
paid
into
Social
Security
dies,
survivor
benefits
can
be
paid
to
certain
family
members.
These
include
widows,
widowers
(and
divorced
widows
and
widowers),
children,
and
dependent
parents.

9.
There
is
a
special
one-­‐time
payment
that
can
be
made
when
you
die
if
you
have
enough
work
“credits.”
This
payment
can
be
made
only
to
your
spouse
or
minor
children
if
they
meet
certain
requirements.
When
a
death
occurs
you
will
need
the
following
information
for
Social
Security
if
you
are
not
already
receiving
benefits
from
Social
Security:
• Proof
of
death-­‐either
from
funeral
home
or
death
certificate
• Your
Social
Security
number,
as
well
as
the
deceased’s
social
security
number
• You
birth
certificate
• Your
marriage
certificate
if
you’re
a
widow
or
widower
• Your
divorce
papers
if
you’re
applying
as
a
surviving
divorced
spouse
• Dependent
children’s
Social
Security
numbers,
if
available
• Deceased
worker’s
W-­‐2
forms
or
federal
self
employment
tax
return
for
the
most
recent
year
• The
name
of
your
bank
and
your
account
number
so
your
benefits
can
be
directly
deposited
into
your
account
If
you
need
a
phone
number
to
your
local
Social
Security
office,
feel
free
to
call
the
funeral
director
you
worked
with
at
the
funeral
home.
He
or
she
should
be
able
to
provide
you
with
the
phone
number.
Armed Forces Information
For
benefits
information
and
claims
assistance
call
1-­‐800-­‐827-­‐1000.
For
government
life
insurance
information
and
claims
assistance
call
1-­‐800-­‐699-­‐8477.
The
National
Cemetery
will
verify
elgibility
of
all
applicants
and
will
maintain
the
schedule
for
the
Committal
Services
at
the
cemetery.
Most
Veterans
who
have
conditions,
are
entitled
to
burial
in
a
National
Cemetery.
Veterans
and
family
members
of
deceased
Veterans
can
request
copies
of
proof
of
veteran
military
service
(DD214)
forms
online
at:
www.archives.gov/research/index.html
You
can
also
use:
www.va.gov
Branch
Served:
___________________________________
Serial
Number:
_______________________
Date
Entered:
___________________________
Place:
__________________________________________
Highest
Grade,
Rank
Received:
_____________________________________________________________
Type
of
Discharge:
_______________________________________________
Date:
__________________
Place
of
Discharge:
__________________________________________________________________________
Location
of
Discharge
Papers
(DD214):
___________________________________________________

10.
Total
Active
Service:
Years
_____
Months
_____
Days
______
Served
in
Wars/Conflicts:
___________________________________________________________________
Citations/Honors/Medals
Received:
_______________________________________________________
Will & Important Documents
Will:
Yes
_____
No
______
Date
of
Will:
__________________________________________________
Will
Location:
________________________________________________________________________________
Executor/Executrix:
_________________________________________________________________________
Name:
_________________________________________________________________________________________
Address:
______________________________________________________________________________________
City:
___________________________________________
State:
______________
Zip:
________________
Prepared
By:
_________________________________________
Phone
#:
__________________________
Address:
______________________________________________________________________________________
City:
____________________________________________
State:
_____________
Zip:
________________
Other
Important
Documents:
_______________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Financial Information
BANKING
Bank:
____________________________________________
Location:
_______________________________
Checking
Account:
_____________________________
Savings
Account:
_______________________
Other:
_________________________________________________________________________________________

11.
Bank:
____________________________________________
Location:
_______________________________
Checking
Account:
_____________________________
Savings
Account:
_______________________
Other:
_________________________________________________________________________________________
Bank:
____________________________________________
Location:
_______________________________
Checking
Account:
_____________________________
Savings
Account:
_______________________
Other:
_________________________________________________________________________________________
Additional
Info:
______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
SAFETY
DEPOSIT
BOX
Bank:
____________________________________________
Location:
_______________________________
Box
Number:
____________________________________
Key:
____________________________________
Other
persons
on
account:
__________________________________________________________________
Additional
Info:
______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Life Insurance
Policy
Location:
______________________________________________________________________________
Insurance
Company:
________________________________________________________________________
Policy
#:
______________________________________________________________________________________
Beneficiary:
__________________________________________________________________________________
Policy
Location:
______________________________________________________________________________

12.
Insurance
Company:
________________________________________________________________________
Policy
#:
______________________________________________________________________________________
Beneficiary:
__________________________________________________________________________________
Policy
Location:
______________________________________________________________________________
Insurance
Company:
________________________________________________________________________
Policy
#:
______________________________________________________________________________________
Beneficiary:
__________________________________________________________________________________
Policy
Location:
______________________________________________________________________________
Insurance
Company:
________________________________________________________________________
Policy
#:
______________________________________________________________________________________
Beneficiary:
__________________________________________________________________________________
Real Estate Assets
Description:
__________________________________________________________________________________
Address:
______________________________________________________________________________________
Location
of
Deed:
____________________________________________________________________________
Description:
__________________________________________________________________________________
Address:
______________________________________________________________________________________
Location
of
Deed:
____________________________________________________________________________
Description:
__________________________________________________________________________________
Address:
______________________________________________________________________________________

13.
Location
of
Deed:
____________________________________________________________________________
Description:
__________________________________________________________________________________
Address:
______________________________________________________________________________________
Location
of
Deed:
____________________________________________________________________________
Other Assets
Description:
__________________________________________________________________________________
Location:
_____________________________________________________________________________________
Description:
__________________________________________________________________________________
Location:
_____________________________________________________________________________________
Description:
__________________________________________________________________________________
Location:
_____________________________________________________________________________________
Description:
__________________________________________________________________________________
Location:
_____________________________________________________________________________________
Description:
__________________________________________________________________________________
Location:
_____________________________________________________________________________________
Description:
__________________________________________________________________________________
Location:
_____________________________________________________________________________________

14.
Personal Property
Item
Beneficiary
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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