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Pre-Arrangement / At-Need Information
The information in the first three sections are needed to complete a death certificate.  However,  it is not necessary to complete every box at this time if you're uncomfortable about sending certain information over e-mail.  We can get the remaining information at a later time.  You may also Print this Form and mail or fax it to us at:  104 Roosevelt Road- Valparaiso, IN  46383    Fax:  (219) 464-9582
We recommend when you have finished completing this form that you Print a Copy in case of any transmitting errors and to keep for your records.
Personal Information
First Name: Last Name:
Middle Name: Social Security #:
Date of Birth Place of Birth:
Home Address: City:
County: State:
Zip Code: Home Phone:
Work Phone: E-mail:
Father's Name: Mother's Name:
Mother's Maiden Name: Marital Status:
Spouse's Name: Spouse's Maiden:
Date of Marriage: Place of Marriage:
Work/Education History
Education (0-12): College (0-5+)
Occupation/Title:
Employer: (Primary)  Employer: (Secondary)
Type of Business: Type of Business:
Years Employed: Years Employed:
Year Retired: Year Retired:
Military Record
Branch of Service: Serial Number:
Date Enlisted: Rank at Discharge:
Date Discharged: Discharge On File At:

Copy of Discharge Papers:  Yes   No
Name of Wars:
Informant  (Only if different than person listed above)
Name: Relationship:
Address: City/State/Zip:
Home Phone: Work Phone:
E-Mail:

Are you the Legal Next-of-Kin or P.O.A.?:
Yes    No

Type of Service and Merchandise Request
Type of Service Traditional Burial   Cremation 
Casket / Urn
Vault
Funeral Service Request
Funeral Home:
Place of Visitation:
Place of Service:
Religious Denomination
Place of Worship:
Lodge/Union:
Person(s) in Charge of Final Arrangements:
Special Instructions
Flower Preference:
Music:
Jewelry:
Glasses:
Clothing:
Casket Bearers: 1.
2.
3.
4.
5.
6.
Other:
Disposition Request
I Already Have Cemetery Spaces: YesNo
 If "Yes" Cemetery Name:
City: State: Zip:
Phone: Section: Lot #
Grave # Is There a Monument In Place? Yes  No
If "No" I Prefer: Cemetery Preference:
City: State: Phone:
Other Instructions
Memorials/Donations
Please Select One or More of the Options Below
  Send Information About Pre-Arrangement
  Contact Me To Set An Appointment
  I Would Be Interested In Pre-Paying Using A Guaranteed Irrevocable Funeral Trust
  Please Keep My Information On File