Pre-Arrangement Form

Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form. Personal Information Full Name   Nickname Address City  State   Zip  Phone  Email  Date of Birth  Place of Birth  Social Security No. Father's Name   Living  Deceased Mother's Name   Living  Deceased Mother's Maiden Name Marital Status Married   Divorced   Widow   Never Married   Other Spouse's Name  Spouse's Maiden Name  Date of Marriage  Place of Marriage  Education/Work History Education Level Grade School (0-8 Years) High School (9-12 Years) Additional Years (13+) Work Status Retired Active Unemployed Disabled Occupation   Type of Industry Employer  Employer City, State  Military Record     Did you serve in the military? Yes No Branch of Service  Service Number  Enlistment Date   Enlistment Place Discharge Date   Discharge Place Rank at Discharge   Conflicts Served Do you have a copy of your discharge papers?   Yes No  If yes, Location of Discharge papers  Church/Organizations/Activities Religious Denomination Name of Church   City,State Organizations or Memberships Activities or Interests Family Information Surviving Children? Yes No List Children's Names, City & State of Residence, Spouse's Name Surviving Sisters? Yes No Include Sister's Names, City & State of Residence, Spouse's Name Surviving Brothers? Yes No Include Brother's Names, City & State of Residence, Spouse's Name Surviving Grandchildren? Yes No No. of Grandchildren   No. of Great-Grandchildren No. of Great-Great-Grandchildren   Additional Surviving Immediate Family Members Predeceased Family Members for Obituary Notice? Yes No Include Names and Relation Family Contact/Person in Charge Full Name   Relationship Address City  State   Zip  Phone  Email  Visitation/Funeral Service Request Funeral Home Location Clairton Elizabeth Versailles Funeral Director Preference Visitation Type Public Private None Service Type Mass Blessing Funeral Service Memorial Service Place of Service Funeral Home Church Cemetery Name of Clergy Disposition/Cemetery Request Disposition Preference Earth Burial Entombment Cremation Cemetery  Phone Number  Address  City, State  Section  Lot  Block No.  Grave No.(s)  Merchandise Request Casket Preference Bronze Copper Metal Stainless Steel Wood Outer Burial Container Preference Concrete Metal Cremation Urn Preference Bronze Hardwood Brass Memory Chest Stainless & Pewter Crystal & Glass Porcelain & Ceramic Cloisonne Marble Clay Composite Biodegradable Clothing Preference My Own Supplied by FH Other Florist Preference   City, State Additional Requests Memorial Contributions or Donations to I have Made a Last Will and Testament Yes No Location of Will Use of Eyeglasses for Visitation Yes No Use of Jewelry for Visitation Yes No If yes, please describe Location of Repast or Funeral Luncheon Additional Instructions Additional instructions for us Please select one of the options below Send me information about pre-arrangement Contact me to set up an appointment No appointment needed, please keep my requests and information on file

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