Your Information
*required information
Your Name
*
Address
*
City
*
State
*
Zip
*
Phone 1
*
Mobile
Home
Work
Phone 2
Mobile
Home
Work
Email
*
Are you a member of this church?
*
Yes
No
Funeral Information
Name of Deceased
*
What was the death date?
*
Was the deceased a member of this church?
*
Yes
No
Proposed Funeral Date
*
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Proposed Funeral Time
*
Start Time
| End Time
Will there be a family hour?
*
Yes
No
Proposed Family Hour Time
Start Time
| End Time
How many people are you expecting for the reception?
Funeral home contact information
Funeral Home Name
*
Funeral Director’s Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
Mobile
Home
Work
Email
*
Funeral Needs
Do you need a minister to perform the funeral?
*
Yes
No
Do you need a musician for the funeral?
*
Yes
No
Do you need special music for the funeral?
*
Yes
No
Do you desire to have the reception at the church?
*
Yes
No
Who will cater the reception?
*
Caterer’s Phone #
Security Code
*
*
Required Information