Deceased Name
	Male Female
Local Address
	City State  Florida Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip
Phone Number
Soc. Sec. Number
Place of Birth
Date of Birth

Education:

	High School   ( 0 - 12)
	College  (1 - 5+ )

Marital Status:

Married

Divorced

Widowed

Never Married

Surviving Spouse ? Yes NoGive maiden name

 

Usual Occupation - Not retired
Kind of Business

 

Fathers name
Mothers Maiden Name

 

Informants Name (You)
Informants Soc. Sec No.
Informant Date of birth
Informant Address
Informant Phone #

 

Military Veteran

Yes   No

( If Yes ) Service No.
Branch of Service
Rank
Enlistment Date and Place
Discharge Date and Place

 

Physician

Family History

Resident of Bradenton since
From: City and State

Obituary Information

Local Obituary	Yes        No
Out of State Obituary	Yes        No
Name of Out of State Paper
No Obituary at all

Surviving Spouse

Spouse Name
Spouse Address
Spouse Phone

Other Relatives

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Name and Relation
Address
Phone

 

Number of Grandchildren

Number of Gr.-Grandchildren

Civic Groups:

Organizations:

Memorial Donations with mailing address:

Funeral Instructions
Type of Services Desired - check boxes.

	Full Service
	Graveside Service Only
	Ship- Out / Full Service
	Ship- Out / No Local Service
	Ship- In / Full Service
	Ship- in / Graveside Only
	Direct Burial
	Anatomical Donation
	Cremation, Full Service
	Cremation, Memorial Service Only
	Cremation, No Services
	Other kind of Service - Please Specify Below

My church affiliation is:

I wish my services to be held at:

I would prefer as clergymen:

I wish my services to be Public or Private .

Name, City, and State of Cemetery

Music selections:

 

Organist:
Soloist:

Pallbearers:

Memorial Book (yes or no) ---- Select ---- Yes No

Service Records (yes or no) ---- Select ---- Yes No

Acknowledgement Cards (yes or no) ---- Select ---- Yes No

No. of death certificates required:
 

Attorney Name

If Cremation, Disposition of Cremains:

Receiving Funeral Home

Name
Address
	City  State Florida Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip
Phone Number

Remarks or Special Requests 

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