Pre-Arrangement Form Please feel welcome to fill out as much information as you have or are willing to provide to us. Thank you.	Step # 1 of 6

* Required Information

*Full Name:
Marital Status:	- Select - Never Married Married Divorced Widow Widower	SSN:
*Date of Birth:		Birth City/State:
Race:		Hispanic/Haitian Origin:	Yes  No
Lawrence, Kansas: (year):  From (city/state):
Address:
City:		State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
County:		Postal Code:
*Phone:		Email:
Spouse's Name:		Spouse's Maiden Name:
Spouse's SSN:		Place of Marriage:
Date of Marriage:		Father's Name:
Mother's Name:		Mother's Maiden Name:

	Step # 2 of 6

Work/Education History
Education (0-12):		College 1-5+:
Occupation:
Business:		Company:

Military Record
Branch of Service:		Serial Number:
Date Enlisted:		Rank at Discharge:
Date Discharged:		Discharge On File At:
Copy of Discharge Papers:  Yes  No
Name of Wars:

	Step # 3 of 6

Funeral Service Request
Place of Service:	- Select - Funeral Home Cemetery Church
Church/Other:
Address:	Phone:
Place of Visitation:	- Select - Funeral Home Church
Religious Denomination:
Place of Worship:
Lodge/Union:

Person in charge of Final Arrangements:
Address:
City:		State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
County:		Postal Code:
Phone:		Email:

	Step # 4 of 6

Special Instructions
Flower Preference:
Music:

Casket Bearers (6):	1.     4.
(leave blank if funeral	2.     5.
staff to perform)	3.     6.

Jewelry:
Glasses:
Clothing:
Other:

	Step # 5 of 6

Disposition Request
I Prefer:	- Select - Earth Burial Cremation
Cemetery:
Address:
Phone:
Property Description:
I have made a last will and testament:  Yes  No
Location:

	Step # 6 of 6

Memberships/Affiliations
Other Instructions (place for you to write your own obituary)
Memorials/Donations to Charity
Please select one of the options below:
	Send information about pre-arrangement Contact me to set up an appointment Please keep my information on file