O′Quinn Peebles Funeral Home

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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.

Funeral Information

Pre-planning.

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

O'Quinn-Peebles Funeral Home, Inc.
1310 South Main Street, PO Box 266, Lillington, North Carolina 27546.
Email: oquinnpeebles@aol.com
Phone: 910-893-3232. FAX: 910-893-3296

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