Reed Funeral Chapel: Pre-Need Form

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