Information About Person Filling Out This Form:

Person Providing This Information

Address of Person Providing Information

City, State, Zip

Phone Number of Above Person:  Home   Cell   Office

How are you related to the person you are making arrangements for? 

Your E-Mail:

Vital Information About The Person You Are Making Arrangements For:

Enter as much information as possible.   If you can't answer a question, we will acquire that fact later. 

First Name   Middle Name   Last Name   

Nickname   Should this nickname be used instead of formal name? (Yes or No)

Physical Address - Mailing Address

City, State, Zip, County

Is residence inside city limits?

Is this person male or female?

Date of Birth - Place of Birth (City, State)

Full Name of Father 

Full Name of Mother (Maiden Name)

Social Security Number

Marital Status   (Never Married, Married, Divorced, Widowed)

Spouse, If Married or Widowed

Date of Marriage

Place of Marriage

Date of Death of Spouse (If Deceased)

The following 4 items are required information for most state death certificates. 

Level of Education 

Usual Occupation

Name of Employer

If retired, former occupation/employer

Military Service (Yes or No)      Branch    

Service Serial Number   Date of Entry   Date of Exit

Is DD-214 available? (Yes or No)   Would you like a flag for the casket? (Yes or No)

 Would you like military honors? (Yes or No)

Church/Religious Affiliations 

Civic Memberships/Affiliations

What newspapers do you want obituaries printed in?  

Name of Hairdresser/Barber 

List other important information or notes that you would like to be placed in the obituary.  This may be used to record accomplishments, hobbies, schools graduated from or other information.

Living Survivor Family Information:

Spouse and City of Residence 

Children and Spouses Plus Their City of Residence

(Example for son: John and Sue Doe, Tallahassee, FL)  (Example for daughter: Karen and Ralph Doe, Tallahassee, FL)

Grandchildren and Spouses Plus Their City of Residence

(Example: John and Sue Doe, Tallahassee, FL)

Great-Grandchildren and Spouses Plus Their City of Residence (Example: John and Sue Doe, Tallahassee, FL)

Brothers and Sisters-In-Law Plus Their City of Residence (Example: John and Sue Doe, Tallahassee, FL)

Sisters and Brothers-In-Law Plus Their City of Residence (Example: Susie and John Doe, Tallahassee, FL)

Living Parents Plus Their City of Residence (Example: John and Sue Doe, Tallahassee, FL)

Preceded In Death By The Following: 

Please List Family Member And Their Relationship To Deceased (Example: John Doe, Father)

Funeral Service Information:

Please note that no specific times or locations can be set until a funeral director works out arrangements with local churches or ministers.  Please call us at 229-377-1414 to let us begin the process of setting a time schedule that will meet your needs.

Place of Funeral Service 

Officiating Minister(s) 

Place of Interment 

Place of Visitation 

Special Music-Songs-Pianist-Organist

Active Pallbearers and Their Phone Numbers

Honorary Pallbearers and Their Phone Numbers

Where will the family be meeting? 

Address of This Location 

Phone Number of This Location 

Would family like memorials given to church or special cause? 

The answers to these questions will help us assist you during this time of need.  Please call us at 229-377-1414 to let us know you have submitted this vital information.   You must press the "Submit" button located below for this information to be forwarded to the funeral home.