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: ____________________________________
