MY Personal Information    Click for Help

Name

Social Security Number

Street Address

City of Residence

County of Residence

State/Province

Country of Residence

Zip

Sex  M   F

Age Last Birthday

Date of Birth

Birth Place

City

State

Country

U.S. Citizen      YES     NO

Naturalization Number

Marital Status

Spouse (maiden name)

Ancestry

Race

Father's Full Name

Father's Birth Place

Mother's Full Name

Mother's Birth Place

Education Highest Level

College
                            (name & dates)

High. School
                           (name/dates)

Grade School
                           (name/dates)

Military Info   Click for Help

Military Service branch

Date Entered

Place where Entered

Separation Date

Separation Place

Grade or Rank

Grade Rank/Rating

Service Serial Number

My Documents Location  Click for Help

Birth Certificate

Marriage License

Mortgage

Other Mortgage 1(?)

Other Mortgage 2(?)

Deed or Notes 1 (?)

Deed or Notes 2(?)

Deed or Notes 3(?)

Income Tax Returns

Military Discharge papers

Automobile Titles

Other Title 1(?)

Other Title 2(?)

Other Title 3(?)

Safety Deposit Box

Will 

Children's Birth  Certificates

Medical History   Click for Help 

Personal Physician

Address

City

State

Zip

Phone

Have Had Treatment for

Cancer 

Circulatory

Diabetes

Heart

Kidney Disease

Tuberculosis

Other

Other

Allergic Reactions To:

Additional Important Medical Information/History:

MY Children [ Address & Phone Numbers]

People To Notify [Address & Phone Numbers]

Organizations I Want Notified [Phone Numbers]

MY Special Arrangements  Click for Help
 

For Social Security Claims 
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I have this information:

Social Security Number

Marriage License

W-2's Last Two Years

Widow's proof over 62

Special Arrangements Made     Click for Help

Long Term Care

Power Of Attorney

Healthcare Power Of Attorney

Guardian & Custodian

Do Not Resuscitate Directive

Living Will

Other Arrangements

MY Financial Information  Click for Help

Banks, Investments [Account/Item Type, Location, 
Account Number, Memo/Description]

Account #1

Account #2

Account #3

Account #4

Account #5

Account #6

Other Financial Matters  Click for Help
[Account Number if Applicable, Description/Disposition]

IRA

Roth IRA

401K Plan

Keogh

Loans I Hold

Liens I Hold

Notes I Hold

Credit Card #1

Credit Card #2

Credit Card #3

Personal Property, Effects & Valuables     Click for Help
[Location, Wish to Go To, Special Instructions]

MY Insurance Information  Click for Help
[Name of Company, Union, Organization, etc., paying MY death benefit, Type of Policy, Location of Policy]

Policy #1

Policy #2

Policy #3

Policy #4

Policy #5

Policy #6

Long Term Health Care

Home Owner

Automotive

Accident

Group

Membership

Union

MY Will [Location & Description, Contact]

My Living Will [Location & Description, Contact]

MY Trust [Location & Description, Contact]

Arrangement for Burial or Crypt Entombment
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My Choice for Final Rest

Burial 
[Desired Location & Lot Description if  available, Current Cost/Value.  Indicate if this is taken care of.]

Lot (s)

Open & Close

Fees

Other Charges

Additional Information & Items/Services about Burial

Mausoleum 
[Desired Location & Lot Description if available, Current Cost/Value, Indicate if this has been taken care of.]

Crypt Space

Open & Close

Fees

Lettering

Vase adornment

Other Mausoleum Charges

Lawn Crypt 
[Desired Location & Lot Description if available, Current Cost/Value, Indicate if this has been taken care of.]

Crypt/Lot Space

Open & Close

Fees

Other Charges Lawn Crypts

Cremation  Click for Help
[Desired Location & Lot Description if available, Current Cost/Value, Indicate if this has been taken care of.]

Cremation Service

Fees (state cremation permit)

Transportation

Traditional Funeral before cremation

Memorial Service

Container

Death Certificates

Cremation Vault

Urn

Niche

Columbarium

Burial /Scatter Garden

Scatter (non-cemetery)

Scatter  in Air

Scatter over Water

Other Disposition

MY Cremation  Special Instructions:

Description of other wishes about MY Final Resting Place

Arrange for Memorials, Caskets, Vaults & Urns 
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Memorial

Material

Size

Cost $

Manufacturer

Style/Description

Customizing, Personal Preferences, Notes & instructions

Preferred Retailer for Monument

Foundation

Size

Cost $

Preferred Retailer for Foundation

Casket

Material

Type of Wood 

Gauge of Steel

Style & Description

Manufacturer

Purchase from

Cost

Vault

Material

Lined Yes  

Manufacturer/Supplier

Cost

Urn

Material

Style, Description & Notes:

Manufacturer

Cost

Arrangements for Funeral Services  Click for Help

Indicate the type of Services you expect;

Basic Service Fee

Embalming Service

Body Preparation

Visitation Personnel

Staff for Services

Transfer of Remains

Vehicles [describe]

Obituary Notices

Documentation& Filings

Flowers [Describe]

Register Book

Acknowledgements

Prayer cards

Forwarding Remains

Receiving Remains

Direct Burial Fee

Choices & Instructions

Memorial Service  (include location)

Religious Service  (include location)

Clergy Choice

Music Selections

Visitation Parameters

My Appearance

Floral Design

Graveside Service

Chapel Service

Music at Cemetery

Special Readings

Pallbearers if Appropriate [Six is an appropriate number]

Pallbearer #1

Pallbearer #2

Pallbearer #3

Pallbearer #4

Pallbearer #5

Pallbearer #6

Choice of Veteran Services at various service locations. Please provide instructions.

Funeral Home Service

Church Service

Cemetery Service

Graveside Service

Additional Instructions & Notes: