Last Name:
First Name:
Middle Name:
Maiden Name: (if applicable)
E-mail:
Address:
City:
Is this address inside the city limits?	Yes  No
County:
State:	AKALARAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY
Zip Code:
Phone:
Cell phone:

Marital Status:	Never Married Married Divorced Widow Widower
Social Security#:
Date of Birth:
Date of Birth:	/ /
Place of Birth:	City State AKALARAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY OR Country
Spouse's Name:
If wife, provide Maiden Name:
Father's First Name:
Father's Middle Name:
Father's Last Name:
Father's Suffix :
Mother's First Name:
Mother's Middle Name:
Mother's Last Name:
Mother's Maiden Name:
Race:	African-American Caucasian Native American Hispanic Country of Origin:

Education:	Primary 0 1 2 3 4 5 6 7 8 9 10 11 12 College 0 1 2 3 4 5+
Usual Occupation: (most of life)
Kind of Business:
Company (Optional):

Branch of Service:
Serial Number:
Date Enlisted:
Rank At Discharge:
Date Discharged:
Discharge On File At:
Copy of Discharge Papers:   YES    NO
Name Of Wars:

Place Of Service:	Funeral Home Church Cemetery
Funeral Home:
Address:
Phone:
Place of Visitation:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person in Charge of Final Arrangements:
Relationship to deceased:
Address:
City:
State:	AKALARAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY   Zip:
Phone:
Cell phone:
Email:

Flower Preference:
Music:
Casket Bearers (6):
Jewelry:
Glasses:
Clothing:
Other:

Important Note: Viewing of the body is a choice of the family. In most cases, embalming is required or recommended for public viewing/visitation, mausoleum entombment, or transfer of remains via common carrier (i.e. shipment by air or rail). When possible, the funeral home needs authorization from the next of kin for embalming. Except in certain cases, embalming is not required by law. Embalming may be necessary, however, if you select certain funeral arrangements, such as a funeral with viewing. If you do not want embalming, you usually have the right to choose an arrangement, which does not require you to pay for it, such as a direct cremation, immediate burial and/or one-time ID viewing for family only.

The family preference regarding viewing/embalming is:

Choose Public Viewing One time ID view for immediate family only Required by choice of disposition No viewing, no embalming Not sure

I authorize Mayer Funeral Home to embalm:

Choose Yes No Will Advise

I Prefer:	Earth Burial Mausoleum Cremation
Cemetery:
Address:
Phone:
Section:
Location:
I have made a last will and testament:   YES    NO
Location:

Please list any other instructions you may have:

Please list any Memorials or Donations to Charity that you would like:

Please select one of the options below: Send information about pre-arrangement Contact me to set an appointment Please keep my information on file

Email: mail@mayerfuneralhome.com

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