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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

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

Branch of Service	Serial Number
Date entered service	Rank at Discharge
Date Discharged	Discharge on file at
Do you have a copy of your discharge papers? Yes No
Wars fought in
Person in charge
Address
Telephone

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