Making Funeral Arrangements: Funeral Preplanning Questionnaire - a Korisko Larkin Staskiewicz Funeral Home Resource

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Please answer the following questions.
When you are finished, press "submit" to continue.

Vital Statistics:

Full Legal Name of the Person this Plan is For:

Date of Birth (MM/DD/YY):

Date of Death (if applicable, MM/DD/YY):

Age: Sex:

Social Security Number:

Place of Birth (City and State or Country if not in USA):

Temporary Address (If applicable; Street, City, State, Zip):

Temporary Telephone Number (with area code):

Permanent Address (If applicable Street, City, State, Zip):

Permanent Telephone Number (with area code):

Do you live inside the city limits? Yes No

What is your race?

What is your nationality or ancestry?

What is your marital status?
Married Divorced Widowed Never Married

Name of Spouse (If Wife, give Maiden Name):

Your Occupation (Job title when working):

In What kind of Business or Industry?

How many years in school?

How many years of College?

Father's full name:

Mother's full maiden name:

Have you ever been in the U.S. Armed Forces? Yes No

Legal Name of Next of Kin or Responsible Party:

Address of Next of Kin or Responsible Party (Street, City, State, Zip):

Telephone Numbers of Next of Kin or Responsible Party:

Home (with area code):

Work (with area code):

Mobile (with area code):

Name of family doctor:

Family doctor's Address:

Family doctor's telephone number (with area code):

Preferred Funeral Arrangements (choices that you make):

Visitation (Calling on the Family of a loved one to offer support and sympathy)

I Prefer a Private Visitation for my Family at the Funeral Home

I Prefer a Private Visitation for my Family at my church

I Prefer a Public Visitation at the Funeral Home

I Prefer a Public Visitation at my church

During Visitation I prefer that my Casket remain closed

During Visitation I prefer that my Casket remain open

I Prefer No Visitation as I wish to be Cremated

I Prefer No Visitation but I would like a Funeral Ceremony

Vigil or Wake (a.k.a. Rosary) Service (Generally a Religious Ceremony Performed in the Evening)

Yes, I would like an Evening Vigil or Wake Service

No, I would not require a Vigil or Wake Service

Funeral Ceremony (Generally a Religious Ceremony Performed during the Day followed by the Committal at the place of Disposition)

I Prefer a Religious / Memorial Ceremony to be held at My Church

I Prefer a Religious / Memorial Ceremony to be held at the Funeral Home

I Prefer a Religious / Memorial Ceremony to be held at some Other location (detail here):

I Prefer No Religious / Memorial Ceremony

Committal / Final Disposition (This means placement in the final resting place of your choice)

I Prefer Ground Interment / Burial

I Prefer Mausoleum Entombment

I Prefer Cremation with the following disposition of my ashes:

Ground Interment of urn

Placement of urn in Niche

Private Placement of urn

Scattering of ashes

Family Fellowship after the Funeral

I Prefer a Luncheon be held at this location (enter here):

I have no Preference

I Prefer No Luncheon after my Funeral

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Veteran's Section:

No, I am not a Veteran (Skip this section)

Yes, I am a Veteran

I served my Country in the (Branch of Service):

I entered the Service on (MM/DD/YY):

I entered the Service at this location:

I left the Service on (MM/DD/YY):

I left the Service at this location:

I attained the rank of:

My service serial number is:

I have visited a V.A. Hospital and my C number is

As an eligible Veteran of this Country I request a U.S. Flag be

Draped on my Casket

Folded in a triangle by my Casket

Folded in a triangle for my Memorial Ceremony

Folded in a triangle for private presentation after funeral

I request a Government Headstone / Marker for my final resting place

Granite

Bronze

I request full Military Honors at my funeral

If I qualify, I request any V.A. Burial Allowance funds

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Details of Funeral Ceremony:
(Optional, however this may help your family to fulfill your wishes)

Theme of Ceremony:

I prefer a Religious Ceremony

I prefer a Military Funeral Ceremony

I prefer a Non Religious Ceremony

I prefer a Lodge or Club Ceremony

I prefer (detail here):

Preferred Minister

Name

Telephone Number (with area code)

Readings

Scripture passages

Special poems

Other Readings

Flowers

The flowers I like are

Instead of flowers, I prefer donations to:

Music (To be played / sung at your service)

I prefer the following popular songs

I prefer the following hymns

I prefer the following musician(s) / vocalist(s)

I prefer just background music before and after ceremony

I prefer no music

Clothing, Jewelry, Eyeglasses, Mementos and Photographs

I prefer the following clothes be used

I prefer the following Jewelry be displayed

I prefer my eyeglasses be

On

Off

I prefer the following mementos be displayed

I prefer the following photographs be displayed

I have other preferences.

Items to be removed before final disposition

Items I want to keep with me

Memorial Cards or Folders

I prefer the smaller prayer card with a poem or religious prayer on the back
I prefer the larger folder with a record of the service and poem or prayer inside

Casket Bearers

I prefer the following as my casket bearers:

Honorary Pallbearers (Optional)

I prefer the following as my honorary pallbearers:

Personal Wishes:

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Korisko Larkin Staskiewicz Funeral Home
5108 "F" Street � Omaha, NE 68117 � Phone: (402) 731-1234 � Fax: (402) 734-2081