Full Name

Date of Birth

Place of Birth
State or Foreign Country,
Citizen of USA or
County of
City of
Township of
Father's Name
Mother's Maiden Name
Hispanic Origin? yes no

Places of residence from birth to marriage with dates:

Schooling: (give names and dates graduated)

Elementary
High School date graduated
College date graduated
Other date graduated
Highest educational level

Marital Status:

Usual place of residence

State of
County of
City of
Give 911 address
Is this in the city limits? yes no
If NO, township of

Length of time at this residence

Social Security Number (be prepared to provide it when you come in)

Name as listed on the social security card
Occupation
Years in this occupation
Retired in moved to or retired in

Service Board

Were you ever in the U.S. Armed Services? yes no
Branch of service
Date of service (WW1, WW2, Etc.)
Serial #
C#
Bring copy of discharge if available.

Church Activities / Spiritual

Member of church
Date and place of baptism
Date and place of confirmation
List activities in church life and offices held with dates

Clubs and organizations

Belonged to what clubs and organizations

Surviving Family

SPOUSE:

Name
Address
City, State, Zip

FATHER:

Name
Address
City, State, Zip

MOTHER:

Name
Address
City, State, Zip

CHILDREN (with names and addresses)

Number of Grandchildren

Number of Great-Grandchildren

Brothers and Sisters (List name of married in order of ages. Include town and state. List names of married sisters. example: Minnie (Joe) Ross  For widowed sisters, list only given name. example: Minnie Ross

Surviving Grandparents (name and address)

Preceded in death

Spouse father mother

Sons Daughters Brothers Sisters

Cemetery

Name of cemetery
Location of cemetery
Name of lot owner

Casket bearers (to be at location 1/2 hour prior to service)

Military Honors

Honorary Casket bearers yes no

Casket bearers should be notified by the family. If necessary, we will assist you in contacting them. We would however, appreciate your listing the telephone numbers of the casket bearers, and especially how to reach those who have no telephone listed in their own name.

IMPORTANT:
(Person preparing this form or the person responsible for doing the family business.)

Name
Relationship
Street or P. O. address
City, State, Zip
Telephone of informant

Extra Information