First Name
Last Name
Street Address
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
ZIP
Phone
E-mail
Date of Birth
Spouse/Partner's Name
Spouse/Partner's Phone
Spouse/Partner's E-mail
Child's Name
Child's Street Address
Child's City
Child's State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Child's ZIP
Child's Phone
Child's E-mail
If you have more than one child, use this box to add the additional children's name(s) , address(es), phone #(s), and email(s)
Family Doctor's Name & Phone #
Who should we contact in case of crisis? Include name, phone #, and email
Veterans – please help your church to be there for you – tell us more about your service below
Who has access to these documents?
If yes, who has access to this information?
Which funeral home/memorial society would you prefer?
Name, Phone #, & Email of Other preferred officiant:
Other persons you would like to be invited to speak?
Music, hymns, poetry, or scripture to be included?
Preferred recipient of memorial gifts?
If yes, where are they located and/or who knows about them?
What were the dates of your service?
What did you do in the military?
If yes, what were your duties?
If yes, who would be the most knowledgeable about your service to coordinate the Honor Guard?
If yes, list name, address, email, & phone # of fellow service member.
Who should receive your American flag?
If yes, which one?
Where is your DD214 (discharge form) located and who has access to it?
Use this space to share any favorite military stories you would like told at the funeral/memorial service:
Use this space to note anything else you would like people to know about you related to your service:
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