Reliable Cremations

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 OneMyselfSpouseLife PartnerMotherFatherChildFriendOther Relative

• ---

• INFORMATION ABOUT THE PERSON FOR WHOM YOU ARE PLANNING:
• Mr / Mrs / Ms
• Sex:    Male
     Female
• Marital Status: Never MarriedMarriedDivorcedWidow(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 OneArmyNavyAir ForceMarinesCoast GuardOther
• 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 OneFuneral HomeChurchCemetery
• Name of Funeral Home:
• Address:
• Phone:
• Place of Visitation:
• I Prefer the Place of Visitation to Be: PublicPrivate
• 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 OneEarth BurialMausoleumCremation
• 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