Journey's End Form

I got this from a friend of mine and thought to share

Very often, the wishes of people surrounding their death and funeral are not put in writing which makes
it very difficult for a family or others to know what to do. This information form has been prepared to
help you carry out your wishes and to help the bereaved family. Please fill out the form as completely
as you like and insert any additional comments. I suggest that you provide one copy for the person
conducting the service, one for your attorney or executor, and one for the funeral director if you have
selected one at this time. If I can help with advice or additional copies or duplicates, please let me
(Preacherr's Name)
A. Personal Information
1. Name:
(given name) (maiden) (surname)
2. Address: --------------------------------------------------------
3. Phone:
4. Date & Place ofbirth: -------------------------------------------------
5. Schools attended & graduation dates:
6. Date moved to this area:
From where: ----------------------------------------------------
7. Occupation (s):
8. Special awards & honors received:
9. Organization affiliations: --------------------------------------------
B. Marriage and Family Information
I. Spouse's name. ___________________________ _
(Given) (maiden) (surname)
If deceased, date: ----------------------------
2. Date and place of Marriage:------------------------
3. Children: Name Residence If deceased, date
4. Grandchildren (please list): _______________________ _
5. Great-Grandchildren:
6. Parents: Father
name residence deceased/ date
maiden name residence deceased/ date
7. Step-Parents: Step-Father
name residence deceased/ date
maiden name residence deceased/ date
8. Brothers and sisters: name residence If deceased. date
C. Obituary: I desire that obituary/death notices to be placed in the following newspapers:
D. Notification of Family and friends
1. [ would like the following persons to be notified immediately of my death.
2. The following persons should be in charge of making the arrangements for my funeral:
3. The executor of my estate is:
Address: ----------------------------------- Phone: ------------------
E. Other Information
1. My Social Security Number is:
2. My Military Service Number is:
Military Discharge (DD-214) is located: ---------------------------------------
3. My Will is located:
4. Records concerning my finances are located:
i ;
A. Body Given For Medical Use
I wish that my body or parts thereof (state which) be used for medical purposes.
(Provisions must be made by proper documentation in accordance with state law.)
B. Mortuary
I have made funeral arrangements with the following Funeral Home:
Name: ---------------------------------- Phone: ---------------------
Address: -------------------------------------------------------------
1 desire the following Funeral Home to make all necessary funeral arrangements:
Name: ----------------------------------- Phone: ---------------------
Address: -------------------------------------------------------------
If the above is out of town, give name of local funeral home who will assist:
Name: ----------------------------------- Phone: ---------------------
C. Funeral Services Desired
V 1. _ I wish to have my body disposed of immediately.
2. _ I wish to have my body cremated by:
Address: ------------------------------------ Phone:
3. Place of interment of ashes: ------------------------------------------
4. I have I have not made arrangements for this interment.
5. I desire my body to be embalmed. (This is necessary if your body is to be viewed.)
6. I wish to be buried in a casket with body viewed for_ days, followed by
a funeral service (body present) or
a memorial service (no body present).
!. _ I desire my body to be clothed as follows: (State what jewelry, special clothes, etc. is to be buried with your body.)
8. I desire the following people to be pallbearers:
1. 2. ________ _
3. 4. _________ _
5. 6. ________ _
9. _ I desire that flowers be given as follows: (State limits on quantity of flowers if desired.
Also, how should flowers be disposed of after the service?)
10. _ I would prefer memorial gifts be designated for the following: (State where memorial gifts are to be sent)
1. -------------------------- -------------------------------------
2. ------------------------------------------------------------
D. Burial Details
1. I desire to be buried at: -------------------------------------------------------
2. _ I desire to be buried in a gyp! at: ---------------------------
3. _ These arrangements have been are already made at:
E. Marker/Headstone
1. _ I desire no marker or headstone of any kind.
2. _ I have made arrangements with the following monument manufacturer:
Name: ---------------------------------------------------------------
E. l\larker/Headstone
3. I desire a flat marker or a headstone.
_Least expensive _Moderately expensive _Most expensive
4.Qualitv of stone (granite, marble, grade,
5.Size of stone _____________ ____________ _
6.Special design, art work and finish desired:
7Message to be engraved on the stone: ------------------
8.Name and address of monument manufacturer: - - -------------
a. I do /do not \\wish any kind of formal worship service to honor my life.
b. _ I Want _ a Memorial Service (no body) or _ a Funeral Service (body present)
c. I wish to have the service at-----------------Church, or
at _______________________ Mortuary,or
at _____________________ ______ _
d. I wish to have the order of service: _ printed for congregational participation.
_ no congregational participation.
e. I would like to have a Committal Service at the cemetery: __yes _no.
f. Theme of Service: -------------------------------
g. _ Scripture Readings:
h._ Hymns : ____________________________________________________ _
i. _Special Music (choir, etc.):-------- ---------- ----------
j. _ Special Organist: _______ ____ ____ __
k. _ Special Prayers (written or chosen by you. Attach if more room needed):
1. Message to guests: Write a message legibly and place it in sealed envelope with this
form marked not to be opened until: --------------------
by: ___________________________________ _
m. _ Meal: I would like to have a repast meal following the service at
ADDITIONAL Information#: -----------------------


Phone #:


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