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In Memory of P. M. Niebur
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Pittsfield Location
530 W. Adams & Franklin St.
Pittsfield, Illinois 62363
Tel: 217-285-5505
Barry Location
Mortimer & Decatur Sts.
Barry, Illinois 62312
Tel: 217-335-2305
Wheelchair accessible
   

Pre-Arrangement Form

Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form.

Personal Information
Full Name
Address
City  State   ZIP 
Phone  Email 
Date of Birth  Place of Birth 
SSN #:
Father's name  Father's Place of Birth 
Mother's name  Mother's Place of Birth 
Mother's maiden name
Marital Status
Spouse's Name  Spouse's Maiden Name 
Place of marriage  Date of Marriage 

Additional Family Members
Please use the area below to enter the names of siblings, children and grandchildren

Work/Education History
Education Level Grade School High School Degree Masters Degree Doctorate
Occupation
Company Name  Business Field 

Military Record     Did you serve in the military? Yes No

Funeral Service Request
Place of Service
Place of Visitation
Religious Denomination  Place of worship 
Lodge/Union/Assoc. Membership
Person in charge of final arrangements

Disposition Request
I Prefer
Cemetery
Details (if applicable) Lot #   Section/letter   Grave # 
Address  Telephone 
I have made a last will and testament   Yes No
Location of Will

Summary Details
Additional instructions for us
Memorial requests or donations to charity
Please select from one of the options below:
Send me information about pre-arrangement
Contact me to set up an appointment
No appointment needed, just keep my requests and information on file
Submit Information

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