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Phone Number and Cell Number:

Date of Birth*:

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State of Birth:

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Doctors Name. Address and Phone Number*:

Spouse's Information

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Father & Mother Information

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Work & Education

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Military Information

Branch Service:

Serial Number:

Date Enlisted:

Rank at Discharge:

Date Discharged:

Discharge on File at:

Copy of Discharge Papers:

Yes

Funeral Service Information

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I Prefer the Funeral Service To Be:

Viewing for Family:

Yes

Viewing for Friends:

Yes

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Lodge or Union:

Disposition Information

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Cemetery:

Address:

Phone:

I Have Made A Last Will & Testament:

Yes

Additional Information

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Music Selections:

Casket Pallbearers:

Jewelry:

Glasses:

Clothing:

Special Instructions

Other Information:

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