Vital Statistics and Funeral Information

The following information is for guidance as you Pre-Plan your funeral.  It is intended to assist those who will be handling your personal affairs.  You can complete this form online, or print out a blank form.  This form can also be submitted to us for safe-keeping.  See below for more details.

 

 

Personal Information             
Name:
Address:
City, St ZIP:
Phone:
Birth Date:
Birth Place:
Status: Never Married     Married     Widowed     Divorced
Spouse's Name:
  Vital Statistics
Social Security #:
Usual Occupation:
Years of Education:
Race:
If Hispanic-List Origin:
Veteran Info: Yes     No
Branch of Service: 
Rank: 
Entered Service: Date:    
:  Place: 
Discharged: Date:    
Place:
Total Years Service
DD-214 Location:
Serial #   VA Claim # 
Is Veteran Receiving VA Benefits?   Yes     No
Do you desire a military funeral?       Yes     No

Survivors

Include names and the city of residence for each living relative.  Deceased relatives can be included below.
This information is helpful for the obituary notices.

Spouse:
Daughters:
Sons:
Parents:
Brothers:
Sisters:
Number of Grandchildren:   
Number of Great Grandchildren:    
Number of Great-Great Grandchildren:    
Preceded in death by:

                        

Please list relation first then the name.

 

                                 Funeral Service Preferences
Place funeral will be held:
Visitation/Wake Information:
Minister(s):
Musicians:
Favorite Song(s):
Pallbearers:   (At least six)
    
Honorary Pallbearers:

I prefer:

   Burial     Cremation      Entombment     Body Donation
Cemetery Info: Name: 

Deeded To: 

Section       Lot     
Grave    Other
Memorials: Church or Charity: 
Address:
One Handling My Affairs: Name:
Address:
Phone:
Insurance Information: Company:
Agent:
Would you like to receive confirmation that we received this information via regular mail?

   Yes            No

Everyone will receive an e-mail confirmation if you provide your e-mail address:
Name of person submitting this information:                
Your e-mail address:

 
 

O'Quinn-Peebles Funeral Home, Inc.     1310 South Main Street, PO Box 266, Lillington, North Carolina 27546     910-893-3232      FAX 910-893-3296

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