| FULL NAME ______________________________________________________
ADDRESS ________________________________________________________
DATE OF BIRTH ____________ BIRTHPLACE __________________________
SOCIAL SECURITY NUMBER _______________________________________
FATHER’S NAME _________________________________________________
(If living, Father’s Address) _________________________________
MOTHER’S MAIDEN NAME ________________________________________
(If living, Mother’s Address)_________________________________
MARITAL STATUS: Married, Single, Widowed, Divorced
(If Widowed, Late Spouse’s Name) ___________________________
PRECEDED IN DEATH BY __________________________________________
_________________________________________________________________
EDUCATION _____________________________________________________
EMPLOYMENT ___________________________________________________
MILITARY SERVICE Y/N BRANCH _________ WAR ____________________
DATE OF ENLISTMENT __________DATE OF DISCHARGE ______________
SERVICE SERIAL NUMBER _________________________________________
RELIGIOUS AFFILIATION ___________________________________________
OTHER ORGANIZATIONAL & PROFESSIONAL MEMBERSHIPS _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
SPOUSE’S NAME _________________________________________________
FULL NAMES OF SONS & WIVES CITY, STATE
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
FULL NAMES OF DAUGHTERS & HUSBANDS
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
FULL NAMES OF SURVIVING BROTHERS & WIVES
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
FULL NAMES OF SURVIVING SISTERS & HUSBANDS
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
NUMBER OF GRANDCHILDREN _______
FULL NAMES OF GRANDCHILDREN & SPOUSES
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
__________________________________________________/_____________________
NUMBER OF GREAT GRANDCHILDREN ___________
NUMBER OF GREAT GREAT GRANDCHILDREN _______________
FUNERAL SERVICES TO BE HELD AT ___________________________________
OFFICIATING CLERGY TO BE __________________________________________
NAME OF CEMETERY ___________________ LOCATION OF LOT ___________
SPECIAL INSTRUCTIONS ______________________________________________
_____________________________________________________________________
CONTRIBUTIONS TO BE MADE TO ______________________________________
______________________________________________________________________
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