120 South Main Street
Winston-Salem, NC 27101
336.722.6122
Fax: 336.722.6922

Information about the person filling out the form:
First Name:
Middle Name:
Last Name:
Email:
* For your records, the information entered in this form will also be sent to the email address provided above.
Street Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP Code:
Phone:
I am planning for:	Myself Spouse Mother Father Child Friend Other relative
Vital information about the person for whom pre-planning is being done:
First Name:
Middle Name:
Last Name:
Maiden Name:
Sex:	Male Female
Marital Status:	Single Married Divorced Widow Widower
Date of Birth:
Place of Birth:
Spouse's Full Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Full Name:
Mother's Full Name:
Mother's Maiden Name:
Work and Education
Education:
Usual Occupation (most of life):
Kind of Business:
Company:
Military
Branch of Service:	Army Navy Air Force Marines Coast Guard Other
Serial No:
Date Enlisted:
Rank at Discharge:
Discharge on file at:
Copy of discharge papers?	Yes No
Name of Wars:
Funeral Service Information
Place of Service:	Funeral Home Church Cemetery
Name of Funeral Home:
Address:
Phone:
Place of Visitation:
Funeral Service:	Public Private
Viewing for Family?	Yes No
Viewing for Friends?	Yes No
Religious Denomination:
Place of Worship:
Lodge/Union:
Person(s) to Finalize Arrangements at Time of Death
Full Name:
Street Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
Special Instructions
Flower Preference:
Music:
Casket Bearers (6)
1)
2)
3)
4)
5)
6)
Jewelry:
Glasses:
Clothing:
Other:
Disposition
I prefer:	Earth Burial Mausoleum Cremation
Cemetary:
Address:
Phone:
I have made a last will and testament:	Yes No
Other Information and Special Instructions
List other instructions or information:
Memorials & Charities
List any memorials or donations to charity:
Contact Options
	Send information about pre-arrangement
	Contact me to set an appointment
	Please keep my information on file