Pre-Need:

Pre-Need funeral arrangements assure that your individual wishes and preferences are carried out. It also helps ease the burden from your family members at this difficult time. Contact us anytime to discuss questions you may have about funeral pre-need arrangements, or use the following form to register your wishes.


Personal Information

First Name:
Middle Name(s):
Last Name:
Telephone Number:
E-mail Address:
 
 
Address:
Town/City:
State:
Zip Code:
Date of Birth:
Place of Birth:
(city&state or County & state)
Marital Status:
Spouses Name:
(Maiden name and full name of wife or husband’s full name)
Highest Education:
Occupation:
(for longest period during working life)
Social Security Number:
Father’s Full Name:
Mother’s Full Name:
(include her maiden name)
 

Person who will be in charge of my funeral arrangements:

 
Name:
Address:
Town/City:
State:
Zip Code:
Telephone Number:


Military Information
Branch of Service:
Description of Service:
(Wars fought in, medals earned, military campaigns)
Veteran’s Service Number:
Rank
Location of Discharge Papers:
Do you wish to have a military graveside service? Yes No
If yes, Who should conduct your service? American Legion
Veterans of Foreign Wars


Family Members
Spouse:
(Address and phone numbers)
Daughters:
(Hometowns and phone numbers)
Sons:
(Hometowns and phone pumbers)
Grandchildren:
(Hometowns and phone numbers)
Sisters:
(Hometowns and phone numbers)
Brothers:
(Hometowns and phone numbers)
Other Relatives:
(List relation, hometowns, and phone numbers)
Those who have preceded you in death:
(List relation, hometowns)


My Funeral Service Preferences
Church Membership:
Place of Service:
(Funeral Home, Church, Graveside, or other)
Clergy:
(Minister's hometown and phone number)
Type of Disposition: Burial
Entombment
Cremation
Other (Describe Below)
Cemetery Property Owned? Yes No
Name of Cemetery:
(Include: Location of Cemetery, City, & State)
Cemetery Preference:
(If property not owned, include location of cemetery, city & state)
Music Selections:
(Organ or piano background, live vocal,
or recorded music)
(If live vocal, include the vocalist,
and their phone number)
(List of songs)
Pallbearers or Honorary Pallbearers:
(Include pallbearers hometown, home phone number, and bearer type designation)
(A = Active Bearer, H = Honorary Bearer)
Lodge, Society, Fraternal Organization:
(List involvement and if you would
like an honor guard)
Flowers:
Memorial Contributions / Donations:
Obituary Information:

(List education and place of schooling, wedding date and place, work history and places I lived and worked, Clubs, Lodges, Hobbies, what I liked doing, significant accomplishments, Boards, Committees and community and Church involvement, etc.)
Do you wish to have memorial photos displayed? Yes No
Any information or special instructions not previously listed:




Please check as many of the following as apply.
Please contact me so that I may select my casket and vault in advance.
Please forward me a copy of my information for my records.
Please contact me if any of my submitted information needs clarification.
File my information for future reference at Johnson's Funeral Home, but please do not contact me.
I would like to discuss my pre-payment options with no obligation, please contact me.
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