Information about the person completing this formI am planning for*Please Choose...MyselfSpouseLife PartnerMotherFatherChildFriendOther RelativeName* First Middle Last Phone*Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County Show Detailed Form? (Not required) Yes No Information about the person you are planning forName First Last Middle GenderPlease Choose...MaleFemaleMarital StatusPlease Choose...MarriedNever MarriedDivorcedWidowWidowerSocial Security # Date of Birth Month Day Year Place of Birth Spouse's Full Name Spouse's Maiden Name Mother's Name Mother's Maiden Name Father's Name Work and EducationEducation (Primary)Please Choose...123456789101112Years AttendedCollege (1-5+)Please Choose...12345+Years AttendedUsual Occupation (most of life) Kind of Business Company Military RecordsBranch of ServicePlease Choose...ArmyNavyAir ForceMarinesCoast GuardOtherSerial Number Discharge on file at Date of Discharge Month Day Year Rank at Discharge Copy of Discharge Yes No Names of War(s)/Conflict(s) Toured Funeral or Memorial Service PreferencesPlace of ServiceFuneral HomeChurchCemeteryOtherName of Funeral Home Address Phone Place of Visitation I prefer the funeral service to bePlease Choose...PublicPrivateViewing of Family Yes No Viewing of Friends Yes No Religious Denomination Place of Worship Lodge/Union Person(s) to Finalize Arrangements at Time of DeathFull Name Street Address City State Zip Phone Special InstructionsFlower Preference Music 1. 2. 3. 4. 5. 6. Jewelry Glasses Clothing Other Disposition OptionsI prefer Cemetery Address Phone Section Other Information and Special InstructionsPlease List any other instructions you would like us to haveMemorials and CharitiesPlease list any Memorials or Donations that you would likeContact Options Send information about pre-arrangement Contact me to set an appointment Please keep my information on file Please send me information about Treasured Memories® Travel Protection ( The Treasured Memories® Travel Protection Plan removes the burden on your family if death occurs away from home. In the event of the death of the beneficiary more than 100 miles from his or her legal residence, Treasured Memories will fully arrange and pay for all costs involved in transportation from anywhere in the world, saving your family thousands of dollars. ) PhoneThis field is for validation purposes and should be left unchanged.