Pre Need Form
Personal Information and Family Instructions
Full Name:
Nick Name:
Address:
City:
State:
Zip Code:
County:
Phone:
Email:
Date of Birth:
Place of Birth:
Social Security #:
Father's Name:
Living
Deceased:
Mother's Name:
Living
Deceased:
Maiden Name of Mother:
Education (0-12):
Education (1-5+):
Occupation:
Status:
Employer:
City & State:
Church Membership:
Social Clubs or Activities:
Veteran Branch of Service:
None
Army
Navy
Air Force
Marines
Coast Guard
Serial Number:
Date Enlisted:
Rank At Discharge:
Date Discharged:
Copy of Discharge Papers:
Yes
No
If Yes, Location of Discharge Papers:
Name of Wars:
Marital Status:
------
Married
Divorced
Widowed
Never Married
Other
Name of Spouse:
Maiden Name of Spouse:
Children (Include City/State of Residence):
Brothers/Sisters (Include City/State of Residence):
Grandchildren:
Great-Grandchildren:
Great-Great-Grandchildren:
Family Contact/Person in Charge:
Address:
City/State/Zip:
Phone:
Memorial Contributions:
Funeral Home:
------
A.J. Bekavac Funeral Home - Clairton
Paul E. Bekavac Funeral Home - Elizabeth
Daniel F. Bekavac Funeral Home - Versailles Borough
Funeral Director:
Phone Number:
Place of Visitation:
Place of Funeral Service:
Clergyman:
I Prefer:
------
Earth Burial
Entombment
Cremation
Cemetery:
Phone Number:
Address:
City/State/Zip:
Section:
Lot:
Block:
Grave Number(s):
I have made a last will and testament:
Yes
No
Location:
Casket Preference:
------
Bronze
Copper
Metal
Stainless Steel
Wood
Outer Burial Container/Vault Preference:
------
Concrete
Metal
Special Instructions
Clothing:
My Own
Other
Jewelry:
Glasses:
Other:
