ONLINE PLANNING FORM

Secure Online Preplanning Form

Online Preplanning Form

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INFORMATION ABOUT WHOM THIS PLAN IS FOR

Who is this plan for?

First Name

Middle Name

Last Name

Gender

Maiden Name

Race

Origin

Are you/they a US Citizen?

Social Security Number

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BIOGRAPHICAL INFORMATION

Birth Date

City of Birth

State of Birth

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FAMILY INFORMATION

Marital Status

Spouse First Name

Middle Name

Last Name

Maiden Name of Spouse

Spouses SSN

Spouses Date of Birth

Is the Spouse Civil Service?

Marriage Date

If Deceased, Date of Death

Father's Name

Address

City

State

Zip Code

Mother's Name

Mother's Maiden Name

Address

City

State

Zip Code

Siblings

Children

Grandchildren

Great Grandchildren

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EDUCATION & WORK

Highest Level of Education

High School Name & Location

College Name & Location

Retired from Job

Occupation

Employer

Kind of Industry or Business

Years at Company

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MILITARY AND/OR CIVIL SERVICE

Veteran

Are you a retired veteran?

Receiving Disability

Branch of Service

Rank

Years Served

Wars Served In

Special Awards/Honors Earned

Other Pertinent Military Information

Civil Service

Retired Civil Service

CSA #

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SERVICE INFORMATION

Funeral/Memorial/Gathering Service Options

Name of preferred Clergy or Officiant

Reception Options

Would you prefer Burial or Cremation?

Final Disposition

Would you prefer to include a graveside/committal service?

Do you own cemetery property?

Marker of Monument

If yes, please specify where the property is located

If no, please specify if you have any property preferences

Please list any musicians and musical selections you would like to include in your services.

Church Membership or Denomination

Religious Preferences

Sunday School Class Name

Please list any poems, religious texts, or readings you would like to be read at your services.

Please list any interests, hobbies, pets, fond memories, favorite places, significant accomplishments, awards, memberships or personality traits for the obituary.

Is there a special story, personal thank you, or message of hope you would like to be read during your services?

Would you be interested in having a balloon release, dove release, or any other kind of unique ceremony during your or your loved one’s service?

Please list 6 to 8 pallbearers

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MEMORIAL DONATIONS

Memorial Donations to

In Lieu of Flowers?

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LEGAL NEXT OF KIN

Name

Phone Number

Address

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YOUR INFORMATION

First Name

Middle Name

Last Name

Phone Number

Your relationship to the person being planned for.

ONLINE PLANNING FORM

Secure Online Preplanning Form

Online Preplanning Form

CONTACT US

McCullough Funeral Home

A Year of Grief Support