Personal Information

First Name:
Middle Name(s):
Last Name:
Telephone Number:
E-mail Address:
 
 
Address:
Town/City:
State:
Zip Code:
Date of Birth:
Place of Birth:
(city&state or County & state)
Marital Status:
Spouses Name:
(Maiden name and full name of wife or husband’s full name)
Occupation:
(for longest period during working life)
Social Security Number:
Father’s Full Name:
Mother’s Full Name:
(include her madien name)

Person who will be in charge of my funeral arrangements:
Name: 
Address: 
Town/City: 
State: 
Zip Code: 
Telephone Number: 


Military Information
Branch of Service:
Description of Service:
(Wars fought in, medals earned, military campaigns)
Veteran’s Service Number: 
Rank 
Location of Discharge Papers: 


Family Members
Spouse:
(Address and phone numbers)
Daughters:
(Hometowns and phone numbers)
Sons:
(Hometowns and phone pumbers)
Grandchildren:
(Hometowns and phone numbers)
Sisters:
(Hometowns and phone numbers)
Brothers:
(Hometowns and phone numbers)
Other Relatives:
(List relation, hometowns, and phone numbers)


My Funeral Service Preferences
Place of Service:
(Funeral Home, Church, Graveside, or other)
Clergy:
(Minister's hometown and phone number)

Type of Disposition: Burial
Entombment
Cremation
Other (Describe Below)
Cemetery Property Owned? Yes No
Name of Cemetery:
(Include: Location of Cemetery, City, & State)
Cemetery Preference:
(If property not owned, include location of cemetery, city & state)
Music Selections:
(Organ or piano background, live vocal,
or recorded music)
(If live vocal, include the vocalist,
and their phone number)
(List of songs)
Pallbearers or Honorary Pallbearers:
(Include pallbearers hometown, home phone number, and bearer type designation)
(A = Active Bearer, H = Honorary Bearer)

 
Lodge, Society, Fraternal Organization:
(List involvement and if you would
like an honor guard)

Flowers:

Memorial Contributions / Donations:

Obituary Information:

(List education and place of schooling, wedding date and place, work history and places I lived and worked, Clubs, Lodges, Hobbies, what I liked doing, significant accomplishments, Boards, Committees and community and Church involvement, etc.)

Any information or special instructions not previously listed:




Please check as many of the following as apply.
Please contact me so that I may select my casket and vault in advance.
Please forward me a copy of my information for my records.
Please contact me if any of my submitted information needs clarification.
File my information for future reference at Scobee Funeral Home, but please do not contact me.
I would like to discuss my pre-payment options with no obligation, please contact me.



219 West Lexington Ave P.O. Box 16 Winchester, KY 40391
859-744-2422 Fax: 859-744-4904

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