New Page 1

Facts and Benefits of Pre-Planning

This form is provided as a service to allow you to record funeral preferences for yourself or a loved one. Once you have filled in the information you may:

        Choose the submit button at the end of the form to send it for filing with us
        Print the completed form and mail it to the address above for us to keep on file
        Print the completed form and place it with your important papers

Information about person completing the form:
Todays Date:
First:
Middle:
Last:
I am planning for my:
E-mail:
Daytime Phone:
Evening Phone:
Fax (If available):

Personal Information about person planning for Be sure to use their Full Legal Name
First Name:
Middle Name:
Last Name:
Street Address:
Mailing Address:
City:
County:
State:
Zip Code:
Sex:
Education Level:
Date of Birth:
Place of Birth:

Length of Stay in County:
Is Home Address Inside City Limits:
Hispanic Origin:
Marital Status
Spouse's Full Name:
Spouse's Maiden Name:
Mother's Name:
Mother's Maiden Name:
Father's Name:

Military Service
Service Branch:
Serial Number:
Place Enlisted:
Date Enlisted:
Place Discharged:
Date Discharged:
VA Claim or File #:

Funeral Preferences
I Prefer The Funeral Service To Be:
Place Of Service:
Name Of Cemetery:
City:
State:
Grave or Niche Location:
Religious Denomination:
Church Affiliation:
	Name:
Viewing For Family:
Viewing For Friends:
I Prefer
For the family selecting cremation, what disposition of the remains would you prefer:
Option:

Funeral Preferences
Musical Selections To Be Played
Musical Selections To Be Sung:
Will Supply CD/Tape
Favorite Bible Passages:
Favorite Literature Or Poems:
Favorite Flower(s):
Favorite Flower Color:

Final Disposition
Preference For Final Disposition Is:	Example: Burial will be in Mt. Olivet Cemetery at Pauls Valley. My space(s) are in Section: Block: Lot: Space:

Obituary Information
Survivor Name	Relationship	City	State

Person(s) To Finalize Arrangements At Time Of Death
Name:
Relationship:
Address:
Daytime Phone: Evening Phone:
Second Contact
Name:
Relationship:
Address:
Daytime Phone: Evening Phone:

Other Information | Special Instructions | Other People To Contact

Please Call Me
Tell Me How To Pre-Pay Expenses
Keep Information On File

L. David CoffeyCopyright © 1999 - Stufflebean-Coffey Funeral Home. All rights reserved. Revised: 05/22/08

L. David Coffey
Copyright © 1999 - Stufflebean-Coffey Funeral Home. All rights reserved.
Revised: 05/22/08