FUNERAL ARRANGEMENTS



This page helps families preparing to make arrangements for their loved ones and provide biographical information for the Obituary and Death Certificates.

Please complete the form below and click submit when finished. This information will help us to have a draft copy of the obituary ready for you to view and correct. We will review all the information submitted on the day arrangements are made. Please leave blank fields if you are unsure of the correct answer. We can complete those fields together on the day arrangements are made.

You may click the button below to download a printable version of this form if you would rather not fill out the online one. Please complete as much of the form as you can and bring it to the arrangements conference.


Biographical Information
Name:
Maiden Name:
Age: Social Security Number:
Address:
City: State: Zip:
Place of Birth: City: State:
Date of Birth:        
Date of Death:        
Occupation:
Was Deceased Retired: Yes No If Retired, How
Many Years
Church, Club, Lodge and School Affiliation
Member of Church:
Member of Clubs or Lodges:
Schools Attended:
Graduating High School:
Graduating College:
Please indicate the highest grade attended if the deceased did not graduate from high school. This is required for the death certificate.
Military Service
Was Deceased a Veteran: Yes No
Branch of Service:
Wars:
Service Id Number:
Enlistment Date:        
Discharge Date:        
Please bring a copy of DD 214 to the funeral home so arrangements can be made for the veteran to receive his flag.
Information Provider & Death Certificate
The funeral home will provide the the person who notified the funeral home with death certificates. Generally, the person who supplies the information is the person in charge of the estate. The informant's name will be placed on the death certificate for contact information.
Informant Name:
Relation to Deceased:
Address:
City: State: Zip:
Phone:
Was Deceased Diabetic:
(Information required for death certificate)		 Yes No
Physicians Names:
How many death certificates are needed?
Death Certificates are required for life insurance policies, brokerage accounts, bonds, CD's, out-of-town banks, annuities, etc. They are issued by the state and cost $6.00 each; we suggest you request no less than 3.
Family
  Living
Father's Name: Yes  No
Mother's Name: Yes  No
Mother's Maiden Name:
Marital Status: Single Married Widowed Divorced
Spouse's Name
(if applicable): 		Yes  No
Living SonsNumber   
Please list sons of the deceased below. Please include spouses' names in parenthises, and also place the city of residence. Please press Enter after each line. A typical line would look like:

John Doe (Wife's Name) City, State
Living DaughtersNumber   
Please list daughters of the deceased below. Please include spouses' names in parenthises, and also place the city of residence. Please press Enter after each line. A typical line would look like:

Jane Doe (Husband's Name) City, State
Living BrothersNumber   
Please list brothers of the deceased below. Please include spouses' names in parenthises, and also place the city of residence. Please press Enter after each line. A typical line would look like:

John Doe (Wife's Name) City, State
Living SistersNumber   
Please list sisters of the deceased below. Please include spouses' names in parenthises, and also place the city of residence. Please press Enter after each line. A typical line would look like:

Jane Doe (Husband's Name) City, State
GrandchildrenNumber   
Please list grandchildren of the deceased below. Please include spouses' names in parenthises, and also place the city of residence. Please press Enter after each line. A typical line would look like:

Jane or John Doe (Spouse's Name) City, State
Living Great-GrandchildrenNumber   
Please list great-grandchildren of the deceased below. Please include spouses' names in parenthises, and also place the city of residence. Please press Enter after each line. A typical line would look like:

Jane Doe (Husband's Name) City, State
Please list any step-grandchildren or great-great-grandchildren in the above box if you want them listed in the obituary.
Living Other Family Members, Special Friends, Caretakers
Please list other family members, special friends, and caretakers that should be listed in the obituary in the following box.
Preceded in Death
Please list any person to be included in the obituary who preceded the deceased in death.

Please enter the name, and please list the relationship to the deceased. For example:

Jane Doe Sister
Service Information
Type of Service: Traditional Cremation
Special Rite: None Military Masonic Knights of Columbus Other
Time for Visitation:
For example, 5:00 - 8:00 PM. Please note that the family visitation will begin one hour before the public visitation. So if you schedule the visitation from 5:00 to 8:00, the family visitation will begin at 4:00.
Time for Funeral:
Location for Visitation: Gash Memorial Chapel    Other   
Location for Funeral: Gash Memorial Chapel    Other   
Attending Clergy:
Cemetery Plot: Yes     No
Cemetery Plot Location:
Pallbearers: (Traditional funeral services have 6 or 8 Casketbearers.)
Honorary Pallbearers: (Please list honorary pallbears in the box below.)
Special Music:
(We provide organ music for the funeral but if you would like any special music during the service by CD please list the songs. We have a large selection of vocal hymns on CD.)
Flowers / Flag:
Please enter the name of a flower shop for the casket spray. The price for a casket spray ranges from $150.00 up, please also note how much you would like to spend on a casket spray.

Please note below if the deceased is a veteran and would like his casket draped with the American Flag.
Flower Shop / Flag:
Clothing / Jewelry:
Please bring all clothing to the arrangements conference, underclothes included. Please bring glasses and jewelry that you would like placed on your loved one also.
Picture Memorial:
Please bring a picture that you would like placed in the local newspapers. Also we have a new video memorial that our staff will set up for you if you would like. Please bring in 25 to 30 pictures to the arrangement conference. We also have picture boards available to take home and prepare for visitation.
Newspaper Notices:
We list the obituary in the following papers: The State Journal, The Anderson News, and The Herald Leader. Please list other papers to whom the obituary should be submitted.

The Lexington Herald Leader will place a 7 line obituary for free. This will include the name, age, city they live in, funeral location, time of funeral, and visitation time.

To go beyond the 7 lines and list family members and other obituary information, the price is $5.97 a line. The Herald Leader charges $75.00 to add a picture.
Memorial Contributions:
Please enter a name and address below if you would like memorial contributions made to a church or an organization.

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