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Brenda D. Shumaker, Supervisor

Jason Sunderland, Supervisor

Pre-Arrangements Form

Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form.

Pre-Arrangement Details

Personal Information

Full Name

Street

City

State/Province

ZIP/Postcode

Telephone

Date of Birth

SSN #

Email Address

Place of Birth

Father's Name

Mother's Name

Mother's Maiden Name

Marital Status

Father's Place of Birth

Mother's Place of Birth

Spouse's Name

Place of Marriage

Spouse's Maiden Name

Date of Marriage

Additional Family Members Please use the area above to enter the names of siblings, children and grandchildren.

Work/Education History

Education Level

Grade SchoolHigh SchoolDegreeMasters DegreeDoctorate

Occupation

Company Name

Business Field

Military Record

Did you serve in the military?

YesNo

Branch of Service

Date Entered Service

Date Discharged

Serial Number

Rank at Discharge

Discharge on file at

Do you have a copy of your discharge papers?

YesNo

Wars Fought In

Person in Charge

Person in Charge Address

Person in Charge Telephone

Funeral Service Request

Place of Service

Place of Service Telephone

Place of Visitation

Religious Denomination

Place of Worship

Lodge/Union/Assoc. Membership

Person in charge of final arrangements

Disposition Request

I Prefer

Cemetery

Lot # (if applicable)

Section/Letter (if applicable)

Grave # (if applicable)

Cemetery Address

Cemetery Telephone

I have made a last will and testament

YesNo

Location of Will

Summary Details

Additional instructions for us

Memorial requests or donations to charity

Please select from one of the options below:

Send me information about pre-arrangements

Contact me to set up an appointment

No appointment needed just keep my request and information on file

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Big Run • Punxsutawney

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