Full Name_______________________________________________________________________
FIRST   MIDDLE   NICKNAME   LAST

Address ________________________________________________________________________
STREET                  CITY/STATE   ZIP CODE
Birthplace __________________________________________________________________
CITY/STATE
Birth Date ___________________________________________________
MONTH / DAY / YEAR
Social Security Number _______--________--___________
Level of Education _________ yrs.
Usual Occupation ________________________________________________________________
Industry / Profession _____________________________________________________________
Normal Physician ________________________________________________________________
NAME                    ADDRESS                  PHONE

If Veteran Branch of Service and Rank _____________________________________________
War and/or Dates of Service _______________________________________________

Marital Status: ____Married ____Widowed ____Divorced ____Never Married
Name of Spouse ____________________________________________ (Maiden Name if Wife)
Name of Father ___________________________________________
Mother’s Maiden Name _____________________________________
Next of Kin _____________________________Relation:_____________ Phone:______________

Next of Kin’s Address_____________________________________________________________
STREET                  CITY/STATE   ZIP CODE

FUNERAL SERVICE INFORMATION:

Type of Service: ____Traditional Funeral ____Graveside Service ____Cremation/Memorial Service

Visitation: ____Evening and Morning of Funeral      ____Day of Funeral ONLY
Cemetery:_______________________________________________________________________
Clothing:____Own Clothing:_____________________________
      ____Purchase from Funeral Home

Type of Casket: ____Wood   Mahogany, Walnut, Cherry, Oak, Pecan, Poplar, Hickory, Pine
                         ____Metal    Bronze, Copper, Stainless Steel, Regular Steel
Color Preference_____________________________

Outer Burial Container:____Concrete Vault ____Metal Vault  ___Non-protective Concrete Box

Obituary in Newspapers/Radio Stations: ____________________________________________
________________________________________________________________________________
Clubs/Organizations to perform Ceremonies: ________________________________________
________________________________________________________________________________

After completing this form, fax it to (618) 252-1812, bring it with you on your next visit or mail it to us at:

Reed Funeral Chapel, 503 East Sloan Street, Harrisburg, Illinois 62946