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NAME (INDICATE FULL MIDDLE NAME)_________________________________________________
MAIDEN NAME OF WIFE (IF APPLICABLE)_______________________________________________
HUSBAND____________________________________________________________________________
RESIDENCE___________________________________________________________________________
SEX____COLOR_____SINGLE___NEVER MARRIED___MARRIED_____WIDOWED____DIV_____
DATE OF BIRTH_______________________PLACE OF BIRTH________________________________
EDUCATION_________________________SOCIAL SECURITY NO____________________________
HOW LONG IN CITY_________________________FROM WHERE_____________________________
OCCUPATION__________________________PLACE OF BUSINESS____________________________
TOTAL YEARS SPENT AT OCCUPATION____________DATE LAST WORKED_________________
RETIRED________
WAR VETERAN YES/NO BRANCH_____________________________________________________
ANCESTRY-(EXAMPLES)- ENGLISH;IRISH;FRENCH;AMERICAN;___________________________
FATHER'S FULL NAME_________________________________________________________________
MOTHER'S FULL NAME(USING MAIDEN NAME)__________________________________________
DESIRED LOCATION OF FUNERAL______________________________________________________
CALLING HOURS (YES OR NO)_________________________
IS CREMATION DESIRED_______________________
NAME OF CEMETERY__________________________________CITY/STATE____________________
_____________________________________________________________________________________
WHAT NEWSPAPERS TO BE NOTIFIED___________________________________________________
______________________________________________________________________________________
CLERGY(NAME )______________________ORGANIST/SOLOIST(NAME)_______________________
CONTRIBUTIONS/FLOWERS_____________________________________________________________
________________________________________________________________________________________
SONS_________________________________________________________________________________
_______________________________________________________________________________________
DAUGHTERS__________________________________________________________________________
_______________________________________________________________________________________
BROTHERS____________________________________________________________________________
_______________________________________________________________________________________
SISTERS_______________________________________________________________________________
_______________________________________________________________________________________
NUMBER OF GRANDCHILDREN_________NUMBER OF GREATGRANDCHILDREN____________
NUMBER OF NIECES___________________NUMBER OF NEPHEWS___________________________
OTHERS_______________________________________________________________________________
CHURCH______________________________________________________________________________
ORGANIZATIONS______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
OTHER INFORMATION__________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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