Information About You (The person who is preplanning)

First Name

Middle Name

Last Name

Email AddressBest email to contact you with.

Last Permanent Address

Street

City

State/Province

ZIP/Postcode

Address within City/Borough limits?

YesNoUnknown

If No, which Township?

Number of Years at ResidenceEstimation is acceptable

Best Telephone Number to Reach You at:

Social Security Number

Date of Birth

City and State of Birth

County of BirthIf known

Are you of Hispanic Origin?

YesNo

RaceIf Other or Multiple Choices, please specify below

Race

Your Fathers Full Name (First, Middle, Last)

Father Living/Deceased

LivingDeceasedUnknown

Your Mothers Full Name (First, Middle, Maiden, Current Last)Include Maiden Name

Mother Living/Deceased

LivingDeceasedUnknown

Marital Information

What is Your Marital Status?

Information about your Spouse (If applicable)

Your Spouses NameInclude Maiden Name (if applicable)

Date of Birth (Spouse)

Social Security Number (Spouse)Needed for assisting us in contacting Social Security Office

City and State of Birth (Spouse)

Date of MarriageOptional

Education

Your Education Level

High School Attended

Year Graduated High School (If known)What year did you graduate high school (if applicable)

College(s) or University(ies) Attended

Education Notese.g., When you graduated from college(s), degree specifications, etc..

Occupation

Usual Occupation (What job do/did you do most of the time?)Please include Job Title(s)

Are you Retired?

YesNo

Employer(s)One per line. Please include number of years worked with each.

Other Job Related Information

Military Information

Are you a Military Veteran?

Yes

If you are NOT a Veteran, is or was your Spouse?

Yes

If neither You or your Spouse are a Military Veteran, please skip to next section.

Do you have a copy of the Honorable Discharge (DD214)?

Yes

Unknown

If you can not locate a copy of the DD214, you can go to the military website and request them to do a search.

Please click HERE or copy the link below to your browser:

https://vetrecs.archives.gov/VeteranRequest/home.html

If you have the DD214 and can send us a copy (by mail or email) please skip to the next section.

Branch of Service

Rank when discharged

Did They Serve During Wartime?

Wartime

Peacetime

Please choose

Served During?

Year Entered MilitaryEnter full date if known

Place Entered (City, State)Where were you or they inducted?

Year Released MilitaryEnter full date if known

Place Released from Active DutyCity, State or Base released from:

Obituary (Optional)

Would you like to place an Obituary in a Newspaper?

Yes

Undecided

Depends on the cost

Newspaper Selection(s)

Erie Times News Paid Obituary (Paid by the line - average cost $350 and above)

Meadville Tribune (Paid by the word - average cost $350 and above)

West County Journal $75-$100 (Weekly Newspaper Publishes on Fridays)

Corry Journal Paid Obituary

Other Newspapers

Please select one or more

We would be happy to help write the obituary for you. If you would like to write your own obituary or have already have one drafted, please skip the Hobbies and Family Members sections.

Hobbies, Interests or Special Things Enjoyed

HobbiesPlease separate with semi-colon

InterestsPlease separate with semi-colon

Special things they enjoyed doingPlease separate with semi-colon

Memorial Donations Organization(s) for people to donate in memory of you.

Contributions / Donations may be made to:Include address or website of organization (if able to)

Family Members (Living and Deceased)

Please Include:

First and Last Name
Spouse (If applicable)
City and State they live in (If surviving)

SonsOne per line: (example: John Doe (Jane) of Edinboro, PA)

DaughtersOne per line: (example: Jayne Doe (Jack) of Edinboro, PA)

GrandchildrenOne per line: (example: John Doe (Jane);

Great-GrandchildrenOne per line: (example: John Doe (Jane);

BrothersOne per line: (example: John Doe (Jane) of Edinboro, PA)

SistersOne per line: (example: Jayne Doe (Jack) of Edinboro, PA)

Other Family / Special Friends that you would want to list.One per line

Visitation / Calling Hours

When would you like Visitation?

Visitation

NO VISITATION

Where would you prefer Visitation be held?

Funeral HomeChurchOther

If Church or Other, please specify locationName of Church / Location and City / State

Preferred Times for VisitationAfternoon Hours

Other Times for VisitationPlease include times and / or duration

Other Information about the Visitation:If there is anything else that you would like us to know about your wishes.

Funeral Service

When would you like the Funeral Service?

Same Day as the Visitation

Following Day of the Visitation

Unsure

Funeral Service

NO FUNERAL SERVICE

Where would you prefer the Funeral Service to be held?

Funeral Home

Church

Same Location as Visitation

Other (Specify)

If Other, please specify locationName of Location and City / State

Name of Church (If applicable)

Would you like a specific Clergy Member?(unable to guarantee they will be available)

Other Information about the Funeral Service:If there is anything else that you would like us to know about your wishes.

Final Disposition

What would you like your Final Disposition to be?

Burial

Cremation

Undecided

Other

Do you own Graves at a Cemetery?

Yes

I am (We are) going to purchase them soon.

I would like help on purchasing graves.

I have permission to use family graves.

Cemetery Namewhere graves are located or would like to purchase

Cemetery LocationCity and State (If not local to Edinboro)

If you or your family own cemetery graves, would the name of the owner be different?

Yes

No, they are under my name.

If yes, please list family members that the graves may be listed under.First & Last Name (Separate with semi colon)

Additional instructions for us:About your final wishes, family members, comments, etc...

Questions that you may have:Please ask questions that you have so we can discuss.

Your Email Address

Please select from one of the options below:

Contact me to set up an appointment to finalize my prearrangement (reviewing info, costs and funding).

Contact me to set up an appointment to review my wishes and costs.

Please send me a price quote based on my information and wishes I have provided.

No appointment needed, just keep my information on file.

I already have an appointment scheduled.

Date of Scheduled Appointmentto confirm we have the same date.

Time of Appointment

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