In the pages that follow, I have written my desires/preferences for decisions you will be asked to make after my death.
Please read through this before making arrangements for my funeral or memorial service.
I want you to know what my preferences are but if following my preferences at some point will bring you more pain and suffering, please know that you are more important than any funeral detail outlined here!

(Signed) _______________________________________ (Date) _____________

Upon my death, regarding donation of my organs:

___ Donate any needed organs or body parts
___ No donations
___ Only those organs or body parts listed here: _______________________________________

Here is some personal information you may need:

My date of birth ____/____/____  Place of birth (city/state) __________________________

Maiden name (If applicable) ___________________________________

Single___   Married___   Widowed___   Divorced___

Spouse of _________________________________.   Married ______ years

Social Security Number ______ - ____ - __________

Occupation_________________________________________________

Kind of Business/Industry ___________________________________________

Baptized? ___ Yes  When? ____/____/____ Where? ______________________
                ___ No

Military Service ___ Yes ___ No
      Branch of Service ____________________  Rank____________________

Enlisted (date) ____/____/____  Discharged ____/____/____

Company & Organization ________________________________________

Campaigns or theatres of war: ________________________________________________

___________________________________________________________________

Highest level of education completed_______Graduated (date) ____/____/____ Degree: __________

School_____________________________________, (city/state)__________________________

Father's Name (First, Middle, Last) _______________________________________

Father's Birthplace: (city/state) _______________________________

Mother's Name (First, Middle, Last) ______________________________________

Mother's Birthplace: (city/state) _______________________________

Mother's Maiden Name_______________________________________

Number of times married (If widowed or divorced) _______

Former spouse(s) _________________________________________________________

Children's Names __________________________      __________________________

                             __________________________      __________________________

                             __________________________      __________________________

Number of Grandchildren______    Number of Great-grandchildren_______

Brothers _____________________________ Sisters _____________________________

              _____________________________              _____________________________

              _____________________________              _____________________________

              _____________________________              _____________________________

              _____________________________              _____________________________

              _____________________________              _____________________________

Funeral Arrangements:

I prefer my funeral to be handled by:

(person) _______________________________________ Phone________________

at ____________________________________________ Funeral Home

Address _____________________________________________________________

What I want done with my remains:

____ Burial at __________________________ Cemetery
____ Cremation, then ____ Disburse ashes: (How?)_____________________________
                                   ____ Burial of ashes: (Where?)____________________________

My preference for a clergy person to conduct the funeral is:

Name_________________________________________

Church____________________________________________________

Address___________________________________________________

City/State __________________________ Phone______________

In addition to the clergy person conducting the funeral/memorial,
I would like the following to speak if they will:

___________________________________________________________

___________________________________________________________

___________________________________________________________

I prefer my funeral/memorial service take place at:

____ The funeral home - Address ________________________________________

____ The church - Address _____________________________________________

____ Other location - Address ___________________________________________

I would like these people to be Pallbearers:                               Honorary Pallbearers:

_________________________________       _________________________________

_________________________________       _________________________________

_________________________________       _________________________________

_________________________________       _________________________________

_________________________________       _________________________________

_________________________________       _________________________________

_________________________________       _________________________________

_________________________________       _________________________________

I prefer:  ____ Memorial gifts ____ Flowers   to:_________________________________________

____________________________________________

____________________________________________

____________________________________________

Favorite music: Favorite scripture, poems or readings:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

For the funeral, dress me in:
 _____________________________________________________

__________________________________________________________________________

Jewelry, awards, pins, glasses, etc. _______________________________________________

__________________________________________________________________________

Person responsible for financial arrangements for funeral / memorial service:

Name_________________________________________

Address___________________________________________________

City/State _____________________________ Phone________________

Biographical information I would like to have mentioned at my service:
_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Regarding the disposition of my property:

____ I have not made a will.
____ You can find my Last Will and Testament at
______________________________________________________ (location)

The Executor of my estate is:

Name_____________________________________________________

Address___________________________________________________

City/State _______________________________ Phone__________________

Location of safety deposit box key:___________________________________

Box (#_________) located at __________________________________

Notify the following insurance companies, unions, lodges, pension funds, etc., paying death benefits:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Person(s) to contact for help and advice in settling my affairs:

Name: ____________________________________________________________

Address: _________________________________ Phone: _________________

Name: ____________________________________________________________

Address: _________________________________ Phone: _________________

Item	Location
Birth Certificate
Marriage License
Deeds
Automobile title(s)
Insurance records
Pension records
Income tax records
Bank records
Stocks/bonds, etc.

Please notify these people about my death:

This brochure is provided as a public service by Hospice of Hope, Inc.

Hospice of Hope also offers bereavement follow-up services to families in our service area upon request.