Pre-Arrangement Questionaire
for
_________________________
(Your Name)
I would like to:
q have a traditional funeral service followed
by burial at _________________________
q have a traditional funeral service followed
by cremation.
q have a simple dignified graveside committal service only.
q be cremated as soon as possible after my death.
I would like my funeral services to be held at:
q Brough-Getts
Funeral Home in Miamisburg, Ohio
q my church____________________________________
q the graveside only
q Other _______________________________________
If possible I wish to have:
q a viewing for friends & family
q private viewing for family members only
q a closed casket visitation and/or funeral
My Clergy/Minister is __________________________
Church ___________________________
ANSWER THESE QUESTIONS REGARDING BURIAL
I would like my casket to:
q constructed of steel q constructed
of wood
q constructed of fiberglass q constructed
of copper or bronze q Other ___________________________________
I would like the color of my casket to:
q Silver q brown q blue q white q pink q green
q gold q other ___________________________________
My grave is located at _____________________Cemetery in _________________________________________________
ANSWER THESE QUESTIONS
REGARDING CREMATION
My cremains are to be place in : q an urn constructed of quality metals q urn constructed
of wood q urn suitable for burial q other ____________________________________
PLEASE
ANSWER THESE GENERAL QUESTIONS
My
address is _____________________________________
________________________________________________
Home
phone (_____) _______________________________
Cell
phone (_____) _________________________________
E-mail
___________________________________________
My
closest family member or friend is __________________
Their
phone number is (_____) _______________________
Their
address is ____________________________________
_________________________________________________
My Social Security number is _____ - ____ - __________
My date of birth is _______________
I was born at ______________________
I
am married to ___________________________________
I was married (date) _______________________________
My
occupation : ___________________________________
My
employer is : ___________________________________
My
Attorney is_____________________________________
My life insurance is with______________________________
My life insurance
policy number is______________________
I q am not q am a veteran of the US Armed Forces
Would you like to set an appointment to pre-arrange your final wishes in person at our funeral home? q yes q no
Do you need to buy a grave(s)? q yes q no
Do you need to purchase a monument? q yes q no
Would you like to receive spiritual help?
q yes q no
Would you like to speak with someone regarding estate planning? q yes q no
Would you like to speak with someone regarding your personal or family finances ? q yes q no
Please
feel free to make a copy of this form for your own records, or you may send us a copy of this form for us to keep on file.
There is no charge for us to establish a pre-arranged funeral file for you. If you are desirous of guaranteeing current prices
for you final wishes, we have several options for pre-payment which will accomplish that for you. We are available 24 hours
a day - 365 days a year to serve you in any capacity regarding your memorialization arrangements If we can assist you in any
way please call us at (937) 866-1001 or 1-800-786-1892 Fax (937)847-9128