Pre-Planning Form - Gilberg-Hartwig Funeral Home

Name*

First Last

Sex*

Race*

Hispanic Origin

Citizen of

Address*

Street Address Address Line 2 City State ZIP Code

Name of Parents (Including Mother's Maiden Name)*

Are Your Parents Living?*

Yes
No

High School Graduate?*

Yes
No

College Graduate?*

Yes
No

Name of School(s) Attended*

Are You Married?

Yes
No

Date of Marriage*

Married Where?*

Spouse's Full Name*

Now Living?

Yes
No

Children's Full Names and Locations

Number of Grandchildren*

Number of Great-Grandchildren*

Siblings (& Spouses) and Locations*

Memberships (Church, Groups, Clubs, etc.)

Military Service (Rank/Dates of Service)

Hobbies, Interests, Favorite Activities

Occupation*

Year Retired*

Type of Service Desired*

Traditional Funeral Services with Calling Hours / Funeral Service / Earth Burial
Graveside Services Only (No Other Service / Calling Hours)
Direct Cremation (No Other Service / Calling Hours)
Traditional Cremation with Calling Hours / Funeral Service / Followed by Cremation
Semi-Traditional Cremation with Direct Cremation Followed by Calling Hours / Memorial Service
Other

Please Specify "Other"*

Where should Services be held?*

Where should Interment / Inurnment take place?*

Do you own cemetary space?*

Yes
No

Is there a Monument / Headstone?

Yes
No

If former Military, should Military Honors be included in the Service?

Yes
No

Favorite Types of Flower(s) for the Service

Favorite Hymns or Songs for the Service

Favorite Scripture Verses, Poems, etc. to be Included in the Service

Memorial Contributions Should Be Directed To:

Pall Bearers and/or Casket Bearers*

Additional Notes