Meislohn-Silvie Funeral Home, Inc.

Pre-Arrangement On-Line

This form is provided as a service to allow you to record funeral preferences for yourself or a loved one. Once you have filled in the information you may:

Choose one of the submit buttons at the end of the form
Or print the completed form and place it with your important papers

Information about person completing the form:
First:		Todays Date:
Middle:		I am planning for my:
Last:		E-mail:
Daytime Phone:		Evening Phone:
Fax (If available):

Personal Information about person planning for Be sure to use their Full Legal Name
First Name:		Sex:
Middle Name:		Marital Status
Last Name:		Education Level:
Date of Birth:		Place of Birth:
Street Address:
Mailing Address:
City:		County:
State:		Zip Code:
Length of Stay in County:		Is Home Address Inside City Limits:
Smoker:		Hispanic Origin:
Spouse's Full Name:		Spouse's Maiden Name:
Mother's Name:		Mother's Maiden Name:
Father's Name:

Military Service
Service Branch:		Serial Number:
Place Enlisted:		Date Enlisted:
Place Discharged:		Date Discharged:
VA Claim or File #:

Funeral Preferences
I Prefer The Funeral Service To Be:
Place Of Service:
Name Of Cemetery:
City:	State:
Grave or Niche Location:
Religious Denomination:
Church Affiliation:
	Name:
Viewing For Family:
Viewing For Friends:
I Prefer
For the family selecting cremation, what disposition of the remains would you prefer:

Funeral Preferences
Musical Selections To Be Played
Musical Selections To Be Sung:
Will Supply CD/Tape
Favorite Bible Passages:
Favorite Literature Or Poems:
Favorite Flower(s):
Favorite Flower Color:

Final Disposition
Preference For Final Disposition Is:	Example: Cemetery Street Town, City, Zip
Deed Holder:
Section Range Plot Other	Example: Section: 1 Range: 35 Plot: 1045

Obituary Information
Survivor Name	Relationship	City	State

Person(s) To Finalize Arrangements At Time Of Death
Name:
Relationship:
Address:
Daytime Phone: Evening Phone:
Second Contact
Name:
Relationship:
Address:
Daytime Phone: Evening Phone:

Other Information | Special Instructions | Other People To Contact

Please Call Me
Keep Information On File

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