Today’s Date:
Information about the person completing this form: Name:
Your Address/City/State:
Telephone:
Email Address:
I am Planning For:
Please Select
Myself
Spouse
Partner
Mother
Father
Daughter
Son
Other relative
Friend
Vital Information about the person you are planning for: Full Name (First, Middle, Last):
Street Address:
City, State, and Zip Code:
Township of Residence:
Mailing Address (If different from street):
City, State, and Zip Code:
Social Security Number (SSA will be notified when death occurs):
Sex: Male Female
Race (American Indian, White, etc.):
Ancestry (Enter all that apply - English, Dutch, etc.):
Hispanic Origin: Yes No
Marital Status:
Birthplace (City & State):
Date of Birth:
Father’s Full Name:
Mother’s Full Name (including maiden):
Spouse’s Full Name (including maiden if applicable):
Is Spouse Deceased: Yes No
If Yes, Year:
Surviving Family Members: Parents:
Spouse/Partner:
Children Oldest to Youngest (including Spouse’s First Name)
Siblings Oldest to Youngest (including Spouse’s First Name):
Grandchildren:
Great-Grandchildren:
Other Relatives:
Special Friends:
Predeceased Family Members: Parents:
Spouse/Partner:
Siblings Oldest to Youngest (including Spouse’s First Name):
Children (including Spouse’s First Name):
Grandchildren:
Great-Grandchildren:
Other Relatives:
Special Friends:
Military Records: Copy of Discharge DD-214 available: Yes No
Branch of Service:
Please Select
Army
Army Air Corps
Army National Guard
Air Force
Coast Guard
Marines
Merchant Marines
Navy
Name of War:
Please Select
WWI
WWII
Korean Conflict
Vietnam Conflict
Desert Storm
Operation Enduring Freedom
Iraqi Freedom
Peacetime Service
Military Funeral Honors Requested: Yes No
Education and Employment: Highest Level of Education:
Occupation:
Kind of Business or Industry:
Retired: Yes No
If Yes, Year:
Employer(s):
Memberships: Clubs:
Organizations:
Achievements:
CONFIDENTIAL FUNERAL SERVICE DETAILS: Service Type:
Please Select
Viewing, funeral & graveside service
Viewing & funeral service w/no graveside service
Graveside-only service
Viewing, followed by cremation & graveside service at a later date
Viewing, followed by cremation w/no graveside service
Cremation, Memorial service & graveside service with cremated ashes present
Cremation, Memorial service w/no graveside service (cremated ashes may / may not be present)
Direct Cremation, no services, cremated remains to be scattered
Direct Cremation, no services, cremated remains to be interred at a cemetery
Public Visitation: Yes No
Suggested Visitation Hours:
Service will be: Public Private
Service at:
Please Select
Church
Funeral Home
Cemetery
Mausoleum
Other Location
Name of Cemetery/Mausoleum:
Has Cemetery plot/Mausoleum space been purchased: Yes No
In Michigan Out of State
Disposition:
Earth Burial
Mausoleum
Entombment
Cremation
Other
For Cremation Cremated ashes to be buried (Location) Cremated ashes to be scattered Cremated ashes to be placed in the care of:
For Body Donation to Medicine Preferred Institution:
Religious Affiliation:
Name of Church:
Member: Yes No
Location of Church:
Music Selections:
Scripture/Poem/Other to be read:
Special Requests:
Casket/Pall Bearers:
Additional Considerations: Memorial Donations:
Other items which may be needed or should be considered would be (jewelry, clothing, glasses, dentures, photographs and personal memorabilia, etc.):
Certified Death Certificates: (We will obtain these from the county of death) Number of Copies Needed (Leelanau County Clerk - $10 first copy,
Newspapers/Obituaries: Traverse City Record-Eagle The Leelanau Enterprise
Free Version Paid Version
Other Newspapers (Please Specify) :