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Pre-Planning

Please complete the following form to begin the pre-planning process.

Personal Information
Name :
Marital Status: 
  
Date of Birth:
Place Of Birth :
Address:
City:
State:
County:
Zip:
Phone:
E-mail:
Spouse's Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Name:
Mother's Name:
Mother's Maiden Name:
Work/Education History
Education(0-12):
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:
Funeral Service Request
Place Of Service:
Place of Visitation:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person in Charge of Final Arrangements:
Special Instructions
Flower Preference:
Music:
Casket Bearers (6):
Jewelry:
Glasses:
Clothing:
Other:
Disposition Request
I Prefer:
Cemetery:
Address:
Phone:
Section:
I have made a last will and testament:     Yes     No
Location:
Other Instructions
Memorials/Donations To Charity
Please select one of the options below
Send information about pre-arrangement

Contact me to set an appointment

Please keep my information on file

E-mail us: AdvancePlanning@RogersFuneral.com