Pre-Arrangement Form


Name

Address

Town & State

Township or Boro

Marital Status and Date

Spouse's Name

Birthplace

Birthdate

Father's Name

Mother's Maiden Name

Phone Number

Email

Church Membership

Clubs & Other Organizations (& Positions, etc.)

Length of Residence Here

Previous Residence

Occupation (& Employer) During Most of Working Years

Other Jobs

Contact Person at Time of Need

Contact Person's Phone Number

Education Background

Veteran? Yes No

If yes, please specify WWII Korean Conflict Vietnam Persian Gulf Other

Dates of Service

Rank, Serial #, Etc.

Are you receiving any pension from the Federal Government for your military service? Yes No


Funeral Details

I request the following: (check all that apply)

Services No Yes; please specify My Church The Funeral Home Graveside


Services Public Private

Other Service Notes

Most interments take place following the service. If you desire a different schedule advise Furman accordingly:

Viewing No Yes; please specify My Church The Funeral Home Graveside


Viewing Public Private

Other Viewing Notes

See general price list for disclosure about Embalming & Viewing. Embalming may be necessary when funeral arrangements with public viewing are selected.

Obituary Notices Lancaster's


Shall a photograph be used for Lancaster's Obituary? Yes No

Flowers Please omit (for notice) OK for public to send. Shall an organization be named to which the public can send

Memorial Contributions? No Yes; please specify


Clothing to be used My Own from Furman's none needed due to type of arrangement.


Number of Death Certificates (fee varies by state)

Casket Preferred

Outer Burial Container Preferred

Cemetery Information

Name on Deed

Other Special Instructions

If cremation arrangements are selected, please answer the following:

Type of container for the Cremains (ashes),
an urn from Furman's box provided by crematory, or container from family.


If applicable, shall the cremains be at the service? Yes No


Disposition of Cremains:
Burial as noted above, Family to retain Family to scatter Scattered at sea through Furman's service. Information on file. Crematory to dispose of Cremains per their policy. Information on file.


Note: Furman Home for Funerals will not hold Cremains (ashes) past a reasonable time to finalize disposition details (one month). After such time, the Cremains (ashes) will be returned to next of kin per insured, return receipt, registered mail. Next of kin assumes all liability that may arise from such shipment, and indemnifies and hold Furman and the crematory harmless from any and all claims that may arise from such shipment.

Outline of Survivors

Regarding the financial arrangements for payment of the funeral expenses:
Bill the estate as needed or, Pre-paid arrangement through Furman's (see accompanying papers and/or contract),
Other pre-paid account, please specify:



These are my requests and I understand that the next of kin or other responsible party will be required to sign a Statement of Funeral Goods and Services selected at the time of need (this is a PA State Board of Funeral Directors requirement) and any other applicable forms such as releases, cemetery or crematory forms, veterans forms, etc.
Yes No