Vital Information

Arrangements Being Made For (full name)


Current Address

City  State Zip Telephone

Date of Birth   Place of Birth   


Father's Name   
Mother's Name (including maiden)

Current Marital Status 
Never Married        Married        Widowed        Divorced

Date of Marriage Place of Marriage

Full Name of Spouse (Maiden)  If deceased, Year of death

Years of residence in present location


Other Cities or Locations 


Interesting facts or hobbies


Education (list school names and last grade completed 0-17)  

Citizen of  Are you of Hispanic origin  yes no  
If Yes then N/A Mexican Cuban Puerto Rican Other

Were you in the military?  yes   no   If yes, complete  Branch

Rank Service Number

Enlistment DateEnlistment Place

Discharge Date   Discharge Place

Service in War N/A WWII Korean Conflict Vietnam Persian Gulf War

Usual or last Occupation 
  
Industry

 Employer 


Number of years in Occupation    
Year Retired

Religious Affiliation   
City of Church Affiliation

Organizations, Groups or Clubs  


Immediate Survivors (names, locations and spouses)

Immediate relatives preceding in death

Service Preferences

Type of Ceremony desired  
Traditional Funeral Service  Graveside Service  Memorial Service  Catholic Mass

Place of Ceremony Name of Clergy/Officiant

Their Church/Organization

Would you like a public visitation?  yes  no  
      
Special visitation requests? 


Casket Bearers 


Honorary Casket Bearers 


Musical Selections 
 

Vocalist   Accompanist

Memorial Contributions


Any other special requests: (details you would like or NOT like included in you arrangements)


Cemetery Name   City   State

Lot Block   Section Space #

If your service plans include cremation, will the ashes be:  Scattered     Buried
    
Where?

Will your service plans include donation to a medical facility?  yes  no

 If yes, the location of the signed body deed

Which medical facility is donation being made to?  
                 University of Iowa               Des Moines University (COMS)

Have you made any arrangements for organ donation?  yes   no

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