Name: Complete address: County of residency: If legal residency is in a township, please name township
here: Date of birth: Place of birth: Marital status, choices---never married, married, divorced,
widowed, if married-how many years, place choice in box: Father's name: Mother's name along with her maiden name: Please describe your work history here,
this would normally mention where you retired from and your job title: If you served in the U. S. military, please
decribe your service here: Check this box if you would like to have military honors: Educational background such as high school,
trade schools and college names: Church and/or membership affilliations: Names of surviving family members, spouse,
children, brothers, sisters, grandchildren or any other names to appear in newspaper announcement along with the name of the
town and state where the survivor resides: Deceased relative's names and their
relationship you would like included in newspaper announcement: In this box, you may place the names of
the newspapers for obituary publication, "The Sentinel", "The Patriot-News" or others: Check this box if you desire a traditional earth burial
as your choice of final disposition: Check this box if you desire cremation as your choice
of final disposition: A viewing can be done with either a traditional or
cremation service. Check here if you would like to have a viewing: A visitation is time for family and friends to gather,
check here if you desire a visitation rather than a viewing: Check this box if you would like the service from funeral
home: If you would like the service from a church,
place name of church and location here: Please list officiating clergy's name here: If you own cemetery lots, please name
cemetery and location here: Check this box if you need more information on National
Cemeteries or other local cemeteries: If you would like memorial contributions
to be made in your name, please specify to whom in this box: Special Requests or if you were able to
determine the type of service you desire from our general price list or the type of casket you desire from our casket photo
gallery...you may specify those items here: Please place your email address here: Please place your phone number here:
