Cremation Planning Questionnaire

Personal Information:

First Name

Middle Name

Last Name

Telephone Number

Email

Mailing Address

Street Address Address Line 2 Town/City State ZIP Code

Date of Birth

Place of Birth

(City/State or County/State or Country)

Marital Status

Spouses Name

(Maiden name & full name of wife or husband’s full name)

Occupation

(for longest period during working life)

Social Security Number

Father's Full Name

Mother's Full Name

(include her maiden name)

Person who will be in charge of my funeral arrangements:

Name

First Last

Mailing Address

Street Address Address Line 2 Town/City State ZIP Code

Telephone Number

Military Information:

Branch of Service:

Description of Service:

(Wars fought in, medals earned, military campaigns)

Veteran's Service Number:

Highest Rank Achieved:

Location of Discharged Papers:

Family Members:

Spouse:

Address and phone numbers

Daughters:

Hometowns and phone numbers

Sons:

Hometowns and phone numbers

Grandchildren:

Hometowns and phone numbers

Sisters:

Hometowns and phone numbers

Brothers:

Hometowns and phone numbers

Other Relatives:

List relation, hometowns, and phone numbers

My Funeral Service Preferences:

Place of Service:

(Funeral Home, Church, Graveside, or other)

Clergy:

(Minister’s hometown and phone number)

Type of Disposition:

Burial
Entombment
Cremation

Cemetery Property Owned:

Yes
No

Name of Cemetery:

Cemetery Location:

Street Address Address Line 2 City State ZIP Code

Cemetery Preference:

(If property not owned, include location of cemetery, city & state)

Music Selections:

(Organ/piano background, live vocal, or recorded music ~ If live vocal include the vocalists names and phone numbers)

Pallbearers or Honorary Pallbearers:

(Include pallbearers hometown, home phone number, and bearer type designation) (A = Active Bearer, H = Honorary Bearer)

Lodge, Society, Fraternal Organization:

(List involvement and if you would like an honor guard)

Flowers:

Memorial Contributions / Donations:

Obituary Information:

(List education and place of schooling, wedding date and place, work history and places I lived and worked, Clubs, Lodges, Hobbies, what I liked doing, significant accomplishments, Boards, Committees and community and Church involvement, etc.)

Any information or special instructions not previously listed:

Please check as many of the following as apply:

Please contact me so that I may select my casket and vault in advance.
Please forward me a copy of my information for my records.
Please contact me if any of my submitted information needs clarification.
File my information for future reference at Mullins Memorial Funeral Home and Cremation Service, but please do not contact me.
I would like to discuss my pre-payment options with no obligation, please contact me.

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Cremation Planning Questionnaire

Personal Information:

Person who will be in charge of my funeral arrangements:

Military Information:

Family Members:

My Funeral Service Preferences:

Cape Coral Location

Fort Myers Location