Expression Of My Personal Wishes For Procedures At The Time Of My Death

Name: ____________________________ Date: __________________

I wish to outline my preference regarding procedures to be followed at the time of my death. I understand that there is nothing legally binding in this expression, and that the ultimate decisions are to be made by my next of kin. I hope that my wishes will be respected as best as possible.

1. I request that the following clergyman who has provided comfort and guidance to me during my lifetime be contacted immediately so that he may office assistance to my family.

____________________________________________

_____________________________________________

_____________________________________________

2. I prefer that the following funeral home be asked to take care of the requested arrangements as indicated herein.

______________________________________________

_______________________________________________

_______________________________________________

3. ( ) I have no objection to a post mortem (autopsy) in the interests of medical research if there is reason to believe it would be beneficial.

4. ( ) If possible, I would like the following organs to be made useful to another person:

_______________________________________________

_______________________________________________

_______________________________________________

5. I prefer that my body be:

( ) Buried in the following cemetery:

______________________________________________

______________________________________________

Family burial plot: Block: _____ Section: _____ Lot: ______

Lot owner: ______________________________________

Location of deed: _________________________________

( ) Placed in a crypt in ______________________________

( ) Cremated, and my ashes be disposed of as follows:

________________________________________________

________________________________________________

( ) Donated to the following institution for anatomical science studies, as per previous arrangements, a copy of which agreement is located:

_________________________________________________

_________________________________________________

( ) Disposed of as follows:

__________________________________________________

__________________________________________________

6. I prefer that there be:

( ) A memorial service (without my body), at the following location:

_____________________________________________________

_____________________________________________________

( ) A funeral service with my body at the following location:

_____________________________________________________

( ) Only a graveside committal service.

( ) No service of any kind.

I request that _______________________________ be asked to conduct any service if he is available.

7. Please notify the following lodge and/or military organizations to arrange for special services:

____________________________________________________________

____________________________________________________________

( ) I would like a flag for the casket (Veterans only). My honorable discharge from U.S. Military Service is located:

__________________________________________________________

8. I prefer that there be:

( ) No limitations or restrictions as to flowers

( ) No flowers

I prefer that there be donation in lieu of flowers to

______________________________________________________________

9. I prefer that there be:

( ) Visiting hours ( ) No visiting hours

Open ( ) Closed ( ) casket during visiting hours.

Open ( ) Closed ( ) casket during funeral services.

10. The following are some favorite hymns or scripture selections I hope can be used in religious service:

______________________________________________________________

_______________________________________________________________

11. INFORMATION NEEDED FOR DEATH CERTIFICATE AND/OR NEWSPAPER NOTICE.

Full Name _____________________________________________________

Full Address ___________________________________________________

Social Security Number ___________________________________________

Birth Date _________________ Birth Place ___________________________

Father's Full Name _______________________________________________

His Birth Place ___________________________________________________

Mother's Full Name _______________________________________________

Her Birth Place ___________________________________________________

Last Occupation __________________________ Since (year) _____________

Last Employer ____________________________________________________

Veteran (war, or dates) ____________________________________________

Married ____ Widowed _____ Divorced _____ Never Married _______________

Name of Surviving Spouse ___________________________________________

Present or past occupation of spouse __________________________________

Surviving: Parents _________________________________________________

Children _________________________________________________________

Brother(s) _______________________________________________________

Sister(s) _________________________________________________________

Number of grandchildren ____________________________________________

Number of great grandchildren _______________________________________

Nieces and nephews _______________________________________________

Memberships: Church ______________________________________________

Lodges __________________________________________________________

Other ___________________________________________________________

12. Relatives and friends to be notified:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

13. Copies of this expression of my wishes are filed with:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

THE ORIGINAL OF MY WILL IS LOCATED: _____________________________

______________________________________________________________

Date: ____________ Signature: ____________________________________