This form is for pre-planning a funeral for the future.

 If you are inquiring for someone who has just died or who's death is imminent,
Please call us at (716) 674-5776 for immediate service.

Personal Information - Vital Statistics

Title  Mr. Mrs. Miss Ms. Dr. Rev.      First Name      Middle Initial     

Last Name      Suffix  None II III Jr. Junior Senior Sr.

Current Address -  Street

City      State      Zip    

County 

Country (USA) 

Sex      Male      Female

Marital Status  Never Married Married or Separated Widowed Divorced

Date Of Birth 

Place Of Birth 
(City & State Or Foreign Country

Social Security # 
                                000-00-0000

Phone       E-Mail 

Spouse's Name     

Spouse's Maiden Name 

Father's Name     

 Mother's Name 

 Mother's Maiden Name 

Work- Education History

Education (0-12)      College 1-5+ 

Occupation (When Working, Not Retired) 

Company 

Type of Business 

City And State Of Business Location 

 
Military Record

Branch of Service  None Army Navy Air Force Marines Coast Guard Selected Reserve Other    Military Serial Number 

Date Enlisted      Rank At Discharge 

Date Discharged    Name Of War  None WWII Korea Post 1/55 Other Vietnam WWi Persian Gulf

Discharge Is Filed At   

I Have A Copy Of The Discharge    Yes        No

Funeral Service Information

Will There Be A Visitation (Wake)    Yes      No

Length Of Visitation  One Day Two Days One Night + One Day Other None

Will There Be A Funeral Service  Yes      No

Place Of service  Funeral Home Church Cemetery None

Religious Denomination 

Place Of Worship 

Organizations - Unions - Lodges  --- List All Relevant Below

 
Disposition Request

I Wish Earth Burial Mausoleum Cremation Other

 Cemetery      Grave Location 

Address      Phone # 

I Have Made A Last Will And Testament    Yes      No

Location Of Will 

Other Instructions

Person In Charge Of Final Arrangements

Name     Phone      Cell Phone 

Address      City    State    Zip 

Please Select All That Apply

Send Information About Pre-Arrangements 

Contact Me To Set Up An Appointment 

Please Keep My Information On File 
A confirmation will be mailed to you