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Durham

Clements - Durham

hillsborough

Clements - Hillsborough

Prearrangements

Personal Information and Family Instructions
Please fill out the information below and we will contact you promptly.

First Name:


Last Name:


Address:


City:                                State:         Zip:
         

County:


Phone:                              Email:
    

Date of Birth:                Place of Birth:
    

Father's Name:                 Living       Deceased
                 

Mother's Name:                 Living       Deceased
                 

Maiden Name of Mother:


Education (0-12):               Education (1-5+):
    

Occupation:                       Status:
    

Employer:                       City & State:
    

Church Membership:


Social Clubs or Activities


Veteran Branch of Service       Serial Number:
    

Date Enlisted:            Rank at Discharge:
    

Date Discharge:               Copy of Discharge Papers
         Yes         No

If Yes, Location of Discharge Papers:


Name of Wars:


Marital Status:                  Name of Spouse:
    

Maiden Name of Spouse:


Children (Include City/State of Residence):


Brothers/Sisters (Include City/State of Residence):


Grandchildren:       Great-Grandchildren:       Great-Great-Grandchildren:
         

Family Contact/Person in Charge:


Address:


City:                                State:         Zip:
         

Phone:                              Email:
    

Memorial Contributions:


Funeral Director:             Phone Number:
    

Place of Visitation:


Place of Funeral Service:


Clergyman:


I Prefer:


Cemetery:                        Phone Number:
    

Address:


City:                                State:         Zip:
         

Section:                          Lot:
    

Block:                              Grave Numbers:
    

I have made a last will and testament:
Yes         No

Location:


Casket Preference:


Outer Burial Container/Vault Preference::


Special Instructions


Clothing:
My Own          Other

Jewelry:


Glasses:


Other:



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