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[Note: Print this information out, copy, and use during the pre-funeral interview with the family.]

DATA FOR THE MEMORIAL SERVICE OF:

Name_________________________________________________

Address_______________________________________________

Place of Birth__________________________________________

Date of Birth___________________________________________

Place of Death__________________________________________

Date of Death_____________________________ Age_________

Cause of Death_________________________________________

Parents:

Father______________________________________________

Mother_____________________________________________

Marriage:

Spouse______________________________________________

Date________________________________________________

Place_______________________________________________

Family: Location:

_________________________ _______________________

_________________________ _______________________

_________________________ _______________________

_________________________ _______________________

_________________________ _______________________

_________________________ _______________________

_________________________ _______________________

_________________________ _______________________

____________Grandchildren ____________Great grandchildren

Educational Background:

High School: ________________________ Year: ___________

College: ___________________________ ___________

             ___________________________ ___________

Church Affiliation: ______________________________________

Social/Civic/Lodges:

_____________________________________________________ _____________________________________________________ _____________________________________________________

Hobbies/Personal Interests:

_____________________________________________________ _____________________________________________________ _____________________________________________________

Characteristics & Qualities of Deceased:

_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

Place of Service:

_____________________________________________________

Date and Time:

_____________________________________________________

Funeral Home & Director in Charge

_____________________________________________________

Interment:

_____________________________________________________

Musicians:

Organist_____________________________________________

Soloist______________________________________________

Order of Service (provide copy for Funeral Home/Musicians)

_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

Favorite Scripture(s):

_____________________________________________________

Favorite Song(s):

_____________________________________________________

Poem(s)/Reading(s):

_____________________________________________________

Other Participants in Service:

_____________________________________________________

Other Pertinent Information:

_____________________________________________________ _____________________________________________________ _____________________________________________________