Pre Needs Form

You may begin the pre-planning process online now, in the comfort of your own home, by filling out our online pre-planning form below. A staff member at Clayton Stevenson Memorial Chapel will contact you very soon after we receive it.

PERSONAL INFORMATION
Full Name*
First Middle Last
Address*
Street Address City State ZIP Code
Phone*
Email*
VITAL STATISTICS
Marital Status*
Date of Birth*
Month
Day
Year
Place of Birth*
Spouse's Name
Spouse's Maiden Name
Place of Marriage
Date of Marriage
Month
Day
Year
Father's Name
Mother's Name
Mother's Maiden Name
Brother(s) Names
Sister(s) Names
Children(s) Names

WORK & EDUCATION
Education (1-12)
College: (1-5+)
Occupation
Business
Company
MILITARY RECORD
Branch of Service
Serial Number
Date Enlisted
Rank At Discharge
Date Discharged
Discharge On File At
Copy of Discharge Papers
- Yes
- No
Name of Wars
Person In Charge
Address
Phone
Insurance Information

FUNERAL SERVICE INFORMATION
Place of Service
- Funeral Home
- Church
- Cemetery
Funeral Home
Address
Phone
Place of Visitation
Religious Denomination
Place of Worship
Lodge/Union
Person in Charge of Final Arrangements

Please include name and phone number.
SPECIAL INSTRUCTIONS
Flower Preference
Music
Casket Bearers (6)
Jewelry
Glasses
Clothing
Other

DISPOSITION REQUEST
I Prefer
Cemetery
Address
Phone
Section
Location
I have made a last will and testament.
- Yes
- No
OTHER INSTRUCTIONS
Please list any other instructions you may have:
Please list any Memorials or Donations to Charity that you would like:
Please select any of the options below*
- Send information about pre-arrangement
- Contact me to set an appointment
- Please keep my information on file
When you push the SUBMIT button, please give the form time to process and send your data. This can take up to 2 mintues to complete.
Name
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