Pre-Planning For YouAnd Your Loved Ones My Pre-Planning Worksheet Step 1 of 6 16% Personal StatisticsFull Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email Address* Would you like to continue to the "Personal Information Part One" section of this worksheet? Select "Yes" to continue or "No" to submit your form information to our team. A member of our staff will be in touch shortly.* Yes No Personal Information Part OneCurrent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*Cell PhonePlace of Birth* City State / Province / Region Date of Birth* Month Day Year Social Security Number Race & National OriginChoose from selectionAmerican Indian or Alaskan NativeAsianBlack, not of Hispanic OriginHispanicBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteOtherPlease indicate race Marital Status*Choose from selectionNever MarriedMarriedWidowedDivorcedSpouse's Name (Maiden)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Spouse's Place of Birth* City State / Province / Region Choose from selectionAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Spouse's Birth Year* Spouse's Social Security Number Was/Is Your Spouse a Veteran?* Yes No Would you like to continue to the "Personal Information Part Two" section of this worksheet? Select "Yes" to continue or "No" to submit your form information to our team. A member of our staff will be in touch shortly.* Yes No Personal Information Part TwoDo you have religious affiliations?* Yes No Religious Affiliation Church High School College Professional School Occupation/Profession Employer Retirement Year (if applicable) Hobbies of Interest Did you serve in the military?* Yes No Military Service: Branch* Military Rank* Date of Military Enlistment* Month Day Year Date of Military Discharge (if applicable) Month Day Year Location of Discharge Papers (if applicable)* Military Serial Number* Would you like to continue to the "Family Information" section of this worksheet? Select "Yes" to continue or "No" to submit your form information to our team. A member of our staff will be in touch shortly.* Yes No Family InformationName of Father* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Name of Mother (Married Name)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Name of Mother (Maiden Name)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Next of Kin Name* First Last Next of kin is your closest living relative.Next of Kin Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Next of Kin Phone*Do you have any siblings?* Yes No How many siblings do you have?*Choose from selectionOneTwoThreeFourMore than fourName of Sibling #1 First Last Name of Sibling #2 First Last Name of Sibling #3 First Last Name of Sibling #4 First Last Please list additional siblings' full names below.Do you have any children?* Yes No How many children do you have?*Choose from selectionOneTwoThreeFourMore than fourChild Name #1 (if applicable)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Child Name #2 (if applicable)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Child Name #3 (if applicable)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Child Name #4 (if applicable)* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Please list additional children names and information below.*Do you have any grandchildren?* Yes No How many grandchildren do you have?*Choose from selectionOneTwoThreeFourMore than fourGrandchild Name #1* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Grandchild Name #2* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Grandchild Name #3* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Grandchild Name #4* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Please list additional grandchildren names and information below.*Would you like to continue to the "Healthcare Information" section of this worksheet? Select "Yes" to continue or "No" to submit your form information to our team. A member of our staff will be in touch shortly.* Yes No Healthcare InformationDo you have a physician?* Yes No Physician Name* First Last Physician Phone*Physician Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you have a secondary physician?* Yes No Physician Name #2 First Last Physician Phone #2Physician Address #2 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Would you like to continue to the "Funeral Essentials" section of this worksheet? Select "Yes" to continue or "No" to submit your form information to our team. A member of our staff will be in touch shortly.* Yes No Funeral EssentialsDo you wish to be buried?* Yes No Do you already own a cemetery lot?* Yes No Please provide your cemetery information below.* Please provide the location of your deed.* Do you wish to be cremated?* Yes No Please provide any additional funeral instructions below.Do you have a pre-arrangement contract?* Yes No If you have already pre-arranged your funeral, you should have a contract with the details of your pre-arrangement.Location of Pre-Arrangement Contract If you have already pre-arranged your funeral, you should have a contract with the details of your pre-arrangement.Location of Preferred Funeral Home A funeral home service is a funeral service held at a funeral home. If you wish to have funeral home services, please describe in the field above.Preferred Church A church service is a funeral service held at a church. If you wish to have church services, please describe in the field above.Preferred Graveside A graveside service is a funeral service held at the gravesite at the cemetery. If you wish to have graveside services, please describe in the field above.Preferred Other If you have other funeral service preferences, please describe in the field above.Would you like to have religious services?* Yes No Religious Services Church* Religious Services Name of Officiating Clergy* First Last General Contact Info for Religious Services* Would you like to have fraternal services?* Yes No Name of Fraternal Services* Fraternal Contact Name* First Last Other information that you would like to be known at the time of a funeral:This information could include favorite hymns, readings, bible passages, songs, flowers, donation suggestions, etc.Newspaper InformationIf you wish to have your obituary sent to specific newspapers, please list them in the space above. Have Questions About Our Services? 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