Adams and Swanson :: Pre-planning Form

Personal Information
First Name:		Middle Name:		Last Name:
Address:		City:		County:
State:		Zip Code:
Phone Number:		Email:

Vital Statistics
Social Security #:		Date of Birth:		Place of Birth:
Father's Name:			Mother's Maiden Name:
Siblings' Names:
Marital Status:		Date of Marriage:		Place of Marriage:
Childrens' Names:

Education / Occupation
Attended School at:				Graduated from:
Occupation:				Employer:

Military Record
Branch of Service:		Service #:		Date Enlisted:
Rank at Discharge:		Discharge on file at:		Date of Discharge:
	Copy of Discharge Papers?

Funeral Service Information
Place of Service:		Church:		Minister:
Lodge/Union:			Person in Charge of Final Arrangements :

Special Instructions
Flower Preference:			Music:
Pallbearers:	1. 2. 3.
	4. 5. 6.
Jewelry:			Glass:
Clothing:			Other:

Disposition Request
I Prefer:		Cemetery:		Location:
I have made a last will and testament:		Yes No

Other Instructinons
Please list other instructions that you may have:


Memorials / Donations
Please list any memorials or donations to charity that you would like:


Options
Please select one of the following options:		I would like information about pre-funding for my funeral arrangements. Contact me to set an appointment. Please keep my information on file.