Pre-planning form

Personal Information
Last Name:
First Name:
Middle Name:
E-mail:
Address:
City:
County:
State:
Zip Code:
Phone:
Vital Statistics
Marital Status:
Social Security#:
Date of Birth:
Place Of Birth:
Spouse's Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Name:
Mother's Name:
Mother's Maiden Name:
Work/Education
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:
Funeral Service Information
Place Of Service:
Funeral Home:
Address:
Phone:
Place of Visitation:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person in Charge of
Final Arrangements:
Special Instructions
Flower Preference:
Music
Casket Bearers (6):
Jewelry:
Glasses:
Clothing:
Other:
Disposition Options
I Prefer:
Cemetery:
Address:
Phone:
Section:
Location:
I have made a last will and testament:   Yes     No
Other Instructions
Please list any other instructions you may have:
Donations
Please list any Memorials or Donations to Charity that you would like:
Please select one of the options below:
Duksa Family Funeral Homes
Pre-planning form