Fox Funeral Home Pre-Need Form

I am planning for 
Personal Information
Name:
Email Address: 
(Email Address required to recieve a copy of this info)
Address: 
*City:  State:   Zip:  
Sex:  Male    Female
SSN:  Phone Number: 
Place Of Birth:  Date of Birth: 
Marital Status:  Spouse: (Maiden Name) 
Place of Marriage:  Date of Marriage:
Father's Name:  Father's Birthplace: 
Mother's Maiden Name:  Mother's Birthplace: 

Survivors:
(Please list the names of survivors, state their relationship to you, their spouses names and the city in which they live as you wish to  have them listed in the newspaper.)

(The following is a guide to assist you.) SURVIVORS: Spouse, Sons, Daughters, Parents, Brothers, Sisters, Grandchildren, (Great), Grandparents, Others

(e.g.. Daughter: Erica Schmidt and her husband Bill of Beatrice)

Predeceased By:



Work History
Occupation:  Business: 
Industry:  Company: 
Number of years:  Year Retired: 

Military Service
Service Branch:  Serial Number: 
Date Enlisted:  Rank at Discharge: 
Date Discharged:  Discharge on File At: 
Combat Action(s): 

Funeral Preferences
I prefer my Funeral Service to be  Public    Private
Visitation:  Yes    No
Place of Service:  Other: 
Conclude Service at:  Other: 
Religious denomination: 
Place of Worship: 
Type of Clergy:  Other: 
I prefer  Burial   Cremation    Entombment

Memorialization Instructions
Musical Selections to be Played 
Will Supply CD/Tape
Musical Selections to be Sung 
Favorite Bible Passages 
Favorite Literature or Poems 
Confirmation Date & Verse 
Donations: 
(e.g.. Cancer Society, Arthritis, Heart and Stroke etc.) 

Final Disposition
Preference for final disposition is:  Ground Interment with 
Mausoleum entombment 
Cremation with 
Cemetery Name: 
Cemetery Address: 
 is owned at above location. 

Special Instructions
Important:  If there is anything you have seen at a funeral which you found objectionable or didn't like please describe it below.  Do you have other special instructions?

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If you have questions or comments, please email them to foxfuneralhome@alltel.net