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TODAY’S DATE______________
NAME (INDICATE FULL MIDDLE NAME)_________________________________________________
MAIDEN NAME OF WIFE (IF APPLICABLE)_______________________________________________
HUSBAND_______________________________________DECEASED Y OR N__DATE____________
RESIDENCE___________________________________________________________________________
SEX____RACE_____SINGLE___NEVER MARRIED___MARRIED_____WIDOWED____DIV_____
DATE OF BIRTH_______________________PLACE OF BIRTH________________________________
EDUCATION____8TH OR LESS___SOMEHS___HS GRAD___ASSOC___BACH___MAST___DOCT
SOCIAL SECURITY NO_________-_______-_______________
HOW LONG IN CITY_________________________FROM WHERE_____________________________
OCCUPATION__________________________KIND OF BUSINESS____________________________
NAME OF EMPLOYER_________________________________________________RETIRED (Y / N)
KIND OF BUSINESS/INDUSTRY_______________________________________________________
TOTAL YEARS SPENT AT OCCUPATION____________DATE LAST WORKED_________________
WAR VETERAN YES/NO BRANCH_____________________________________________________
FATHER'S FULL NAME_________________________________________________________________
MOTHER'S FULL NAME(USING MAIDEN NAME)__________________________________________
DESIRED LOCATION OF FUNERAL______________________________________________________
CALLING HOURS (YES OR NO)_________________________
IS CREMATION DESIRED (Y/N)_________BEFORE OR AFTER SERVICES_____________________
NAME OF CEMETERY__________________________________CITY/STATE____________________
WHAT NEWSPAPERS TO BE NOTIFIED___________________________________________________
______________________________________________________________________________________
PHOTO IN PAPERS Y OR N______________________________________________________________
CLERGY(NAME )______________________ORGANIST/SOLOIST(NAME)_______________________
CONTRIBUTIONS/FLOWERS_____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SONS_________________________________________________________________________________
_______________________________________________________________________________________
DAUGHTERS__________________________________________________________________________
_______________________________________________________________________________________
BROTHERS____________________________________________________________________________
_______________________________________________________________________________________
SISTERS_______________________________________________________________________________
_______________________________________________________________________________________
NUMBER OF GRANDCHILDREN__________(NAMES)___________________________________
______________________________________________________________________________________
NUMBER OF ______GREATGRANDCHILDREN:________GREATGRAND:________G-G-GRAND
NUMBER OF NIECES___________________NUMBER OF NEPHEWS___________________________
PRE-DECEASED FAMILY_______________________________________________________________
CHURCH______________________________________________________________________________
ORGANIZATIONS______________________________________________________________________
_______________________________________________________________________________________
OTHER INFO FOR OBITUARY (activities/hobbies)____________________________________________
_______________________________________________________________________________________
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