Personal Information

First Name*

Middle Name

Last Name*

Phone Number*

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Home Address

City or Township

State

Zip Code

County of Residence

Email Address

Name Of Doctor

Name Of Clinic

Biographical Information

Date of Birth

City of Birth

Mothers First Name

Mothers Middle Name

Mothers Maiden Name

Fathers First Name

Fathers Middle Name

Fathers Last Name

Marital Status
MarriedWidowedDivorcedNever Married
Name of Spouse (Maiden Name if Wife)

Date of Marriage

Place of Marriage

Military Information
ArmyNavyAir ForceMarinesOther
Years of Education

Schooling Information

History of Residence

Usual Occupation

Employer

Years Employed

Date Retired

Memberships

Church Affiliation

Church Location

Organizations
St Joseph's SocietyKnights of ColumbusDaughters of IsabellaChristian MothersLion's ClubRotary ClubKiwanis ClubShriners ClubVFWLegionEagles
Other Organizations

Family

Please list their Name / their Spouses Name (if applicable) / and their City of Residence for Example: Johnathan (Jane) Smith, Minneapolis MN
Children

Brothers and Sisters

Number of Grandchildren

Number of Great-Grandchildren

Number of Great-Great Grandchildren

Preceded by Mother
YesNo
Preceded by Father
YesNo
Preceded by Spouse
YesNo
Date of Spouses Death (If Applicable)

Service Information

Visitation Information

Visitation
Visitation at Funeral HomeVisitation ONE HOUR prior to ServiceNO VisitationVisitation at Different Location
Other Location Desired

Funeral Information

Funeral Ceremony
Funeral at Funeral HomeFuneral at ChurchMemorial ServiceNO ServicesGraveside Service
Place of Funeral Ceremony

Officiant

Cemetery Information

Visitation Information

Burial
Earth BurialCremationEntombment (Casket)Innichment (Urn)Cremains to FamilyGraveside
Name of Cemetery

Obituary
St Cloud TimesStar TribunePioneer PressStearns Morrison EnterpriseMorrison County RecordMelrose BeaconSt Joe NewsleaderSauk Centre HaroldClearwater
Other Newspaper Desired