Street Address:

City, State, Zip Code:

City/Village, or Township:
(Circle One)

City              Village            Township

County:

Phone:

Home:                               Cell:

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:

Name of People to Handle Arrangements:

Full Name of Father:

Full Name of Mother:
(Include Maiden Name)

Highest Education Level:

Name of High School:

Name of College:

Marital Status:
(Circle One)

Married      Never Married     Divorced    Widowed

Full Name of Spouse:

Date of Marriage:

Place of Marriage:

Employment History:

Military Service:
(Attach Copy of Discharge Papers)

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

Organizations & Memberships:

Names of Surviving Family Members:
(Include the Name of Spouse & City Where They Live)

Names of Family Members Preceded in Death:

Place of Visitation:

Place of Funeral Service:

Church Affiliation:

Name of Clergy:

Names of Casket Bearers:

Special Services Desired:

Military Tribute Desired:
(Circle One)

Local VFW                          State Honor Guard

Name(s) of Special Songs Desired:

Name of Organist Desired:

Name of Soloist Desired:

Name of Hairdresser:

Name(s) of Special Scriptures Desired:

Date of Your Baptism:

Date of Your Confirmation & Confirmation Verse:

Date:                                         Verse:

Favorite Flower(s):

Name of Flower Shop Desired:
(Circle if You Will do the Ordering or We Should Take Care of it)

Name:

You will Order             We Should Take Care of it

Memorial Donations Designated to:

Cemetery:

Name:                               Lot #:

Cemetery Marker:
(Circle One)

Already Have                      Need One

Veteran’s Marker:
(Circle One)

Full Plaque (24x12)              Niche Plaque (8x5)

Disposition Choice:
(Circle One)

Burial        Cremation          Burial After Cremation

Casket Preference:

Urn Preference:

Vault Preference:

Memorials:

Verse inside Memorials:

Acknowledgements:

Special Instructions:

Names of Newspapers for Obituary:

Berlin Journal              Oshkosh Northwestern
Waushara Argus          Other:

Funding for Irrevocable Funeral Trust:

Copies needed:

I chose Barbola Funeral Chapel because: