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Reliable Cremations
Proudly Serving The Entire San Francisco Bay Area Since 1991
510-938-5255
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Plan a Funeral
Pre-Budgeted Funeral Service Plan
INFORMATION ABOUT THE PERSON COMPLETING THIS FORM:
Mr / Mrs / Ms
*
Email:
*
Street Address:
City:
County:
State:
Zip Code
Phone Number
Alternative Phone Number
Person for whom I am planning
Choose One
Myself
Spouse
Life Partner
Mother
Father
Child
Friend
Other Relative
INFORMATION ABOUT THE PERSON FOR WHOM YOU ARE PLANNING:
Mr / Mrs / Ms
Sex:
Male
Female
Marital Status:
Never Married
Married
Divorced
Widow(er)
Social Security #:
Date of Birth:
Place of Birth:
Spouse's Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Name:
Mother's Name:
Mother's Maiden Name:
WORK AND EDUCATION:
HIgh School:
College:
Occupation:
Company:
MILITARY RECORDS:
Branch of Service
Choose One
Army
Navy
Air Force
Marines
Coast Guard
Other
Serial Number
Date Enlisted:
Rank at Discharge:
Date Discharged:
Discharge on File At:
Copy of Discharge Papers
Yes
No
Name(s) of War(s)/Conflict(s) Toured:
FUNERAL SERVICE INFORMATION:
Place of Service
Choose One
Funeral Home
Church
Cemetery
Name of Funeral Home:
Address:
Phone:
Place of Visitation:
I Prefer the Place of Visitation to Be:
Public
Private
Viewing for Family
Yes
No
Viewing for Friends
Yes
No
Religious Denomination:
Place of Worship:
Lodge/Union:
PERSON(S) TO FINALIZE ARRANGEMENTS AT TIME OF DEATH:
Mr /Mrs / Ms
Street Address
City
State
Zip
Home Phone Number
Alternative Phone Number
E-Mail
SPECIAL INSTRUCTIONS:
Flower Preference:
Music:
Casket Bearers (x6):
1.
2.
3.
4.
5.
6.
Jewelry:
Glasses:
Clothing:
Other:
DISPOSITION OPTIONS:
I Prefer:
Choose One
Earth Burial
Mausoleum
Cremation
Cemetery:
Address:
Section:
I Have Made a Last Will and Testament:
Yes
No
OTHER INFORMATION & INSTRUCTIONS:
Please list any other instruction or information you would like us to have:
MEMORIALS & CHARITIES:
Please list any memorials or donations to charity that you would like to declare:
OPTIONS:
Please select one of the options below:
Send Information About Pre-Arrangement
Please Keep My Information On File
Contact Me To Set Up An Arrangement