Vital Statistics Information

Name (First, Middle, Last) _________________________________________________

Sex � M � F

Address _________________________________________

City _____________________________ State ________

Phone No. _______________________________________

Birth Date ______________________________________

Birthplace ______________________________________

Citizenship _____________________________________

Social Security Number __________________________

Marital Status � Single � Married
� Widowed � Divorced

Spouse�s Name (If wife, give maiden name) _________________________________________________

Occupation (Former if retired) _______________________________________________

Highest Level of Education (Enter # of years) _____

Father�s Name (First, Middle, Last) _________________________________________________

Mother�s Maiden Name (First, Middle, Last) _________________________________________________

_________________________________________________


Veteran �Yes � No
Veteran�s Administration Claim No. ______________________________________

Personal Wishes
1. I would like the service to be held at ________________________________________________

2. I desire the following music _________________________________________________ _________________________________________________

_________________________________________________

3. My preference for clergyman is
(Name and his/her church)

_________________________________________________

_________________________________________________

4. I would like to be buried at
_________________________________________________

5. I desire to be buried with

_________________________________________________

Special Instructions

1. Favorite Scriptures: _________________________________________________

_________________________________________________

2. Favorite Poems: _________________________________________________

_________________________________________________

3. Other Thoughts: _________________________________________________

_________________________________________________

_________________________________________________

Special Requests _________________________________________________ _________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

Special InstructionsSpecial InstructionsSpecial RequestsSpecial RequestsPersonal WishesPersonal WishesVital Statistics InformationVital Statistics Information