Barbola Funeral Chapel

Full Legal Name:


Street Address:


City, State, Zip Code:


City/Village or Township:

(Select one, list township if applicable)

City
Village
Township

Phone:


Email:


Date of Birth:


Place of Birth:


Social Security Number:


Full Name of Next of Kin:


Mailing Address of Next of Kin:


Phone Number of Next of Kin:


Name of Power of Attorney:


Name of Personal Representative:


Name of Attorney:


Names of People to Handle Arrangements:

(Include address and phone number if different from above)

Full Name of Father:

(Include middle name)

Full Name of Mother:

(Include middle and maiden name)

Highest Level of Education:


Name of High School:


Name of College:


Marital Status:

Married
Never Married
Divorced
Widowed

Full Name of Spouse:

(Include maiden name)

Date of Marriage:


Place of Marriage:


Employment History:


Military Service:

(Attach copy of discharge papers)

Branch:
Enlistment Date:
Serial Number:
Highest Rank:
Discharge Date:
Location:

File:

Organizations, Memberships, Hobbies, and Interests:


Names of Surviving Family Members:

(Include the name(s) of spouse/relative and your relationship to each)

Names of Family Members Preceded in Death:

(Include your relationship to each)

Place of Visitation:


Place of Funeral Service:


Church Affiliation:


Name of Clergy:


Names of Casket Bearers:


Special Services Desired:


Military Tribute Desired:
Loval VFW
State Honor Guard

Name(s) of Special Songs Desired:


Name of Organist Desired:


Name of Soloist Desired:


Name of Hairdresser Desired:


Name(s) of Special Scriptures Desired:


Date of Your Baptism:


Date of Your Confirmation:


Confirmation Verse:


Favorite Flower(s)/Color(s):


Favorite Color(s):


Memorial Donations Designated to:


Cemetery Information:
Name:
Block Number:
Lot Number:
Space Number:

Cemetery Marker:
Have One
Need One

Veteran's Marker:
Full Plaque (24x12)
Niche Plaque (8x5)
Medallion

Disposition Choice:
Burial
Cremation
Burial After Cremation

Casket Preference:

(Wood or Metal)

Urn Preference:


Vault Preference:


Memorials:


Verse Inside Memorials:


Acknowledgements:


Special Instructions:


Names of Newspapers for Obituary:


Funding for Irrevocable Funeral Trust:


Copies Needed: 1 2 3 4 5

I Chose Barbola Funeral Chapel Because: