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Signature: _________________________________
Date:
_________________________________
Witness: ______________________________________
Date:
_________________________________
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People to Notify
List family, friends,
and associates who should be notified of your death.
Name __________________________________________________________
Relationship ______________________________________________________
Address _________________________________________________________
City _________________________
State ______________ Zip Code _______
Home Phone ______________________
Business Phone ___________________
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Name __________________________________________________________
Relationship ______________________________________________________
Address _________________________________________________________
City _________________________
State ______________ Zip Code _______
Home Phone ______________________
Business Phone ___________________
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Vital Statistics
Name:
Street address
City/State/Zip
Years at this address
Social Security Number
Date/Place of Birth
Resided in present county since
Resided in present state since
Citizenship
Occupation/Employer
Years of employment
Education
Achievements
Marital status/date/spouse's name
Maiden name
Nickname
Veteran's serial or regimental number
Rank
Name of any war
Place and date discharged
Father's name/place of birth
Mother's name/place of birth
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Funeral Preferences
Funeral director
Place of service
Type of service
Clergy or lay person
Special requests
Preferred casket
Clothing/jewelry instructions
Lodge/society/fraternal organizations
Music
Organist/singer
Donations
Cemetery name
Cemetery location
Property owned? (lot number, etc.)
Final disposition (earth, mausoleum
entombment, cremation/inurnment, other)
Memorial tablet
Type and inscription
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Remembrances/Eulogy
Some of my favorite things
Poem/scripture
Song/music
Flower
Color
Places
Quote
Pets
Hobbies
One of my fondest memories
I want to be remembered for
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Obituary Information
Newspapers to notify
Spouse, widow or widower
of
Place of death
Date of death
Father's name
Mother's maiden name
Children and their places
of residence
Grandchildren and their
places of residence
Brothers/Sisters and their
places of residence
Place/date of birth
Education
Married
Wedding date
Religious affiliation
Clubs/lodges
War record
Employment information
Achievements
Other information to include
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Location of
Important Papers
Birth certificate
Marriage certificate
Insurance policies
Will and testament
Savings account passbooks
Bank accounts/numbers
Stocks/bonds/mutual funds certificates
(brokerage accounts)
Military records
Automobile record
Location of papers
Property owned
Mortgage holders
Retirement plans
Safe deposit box
Attorney
Physicians
Credit Cards Institutions
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