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VITAL STATISTICS INFORMATION FOR A PREPLANNED FUNERAL AT BRUST FUNERAL HOME

You can open a funeral planning file without charge by completing the following information and forwarding it to Brust Funeral Home. You can print and mail this form or send it via e-mail.

Name:
Email Address
Address:
County:
City, State, Zip:
Phone:
Date of Birth:
Birthplace:
Marital Status: Single Married
Widowed Divorced
Name of Spouse:
Maiden Name:
Sex: Male Female
Social Security #:
Usual Occupation:
Kind of Business or Industry:
Education
Highest Grade Completed:
Less Than High School
0-12 College 1-4, 5+
Race
(If Hispanic Origin, Specify Cuban, Mexican, etc.)
Father’s Full Name:
Mother’s Full Maiden Name:
In Event of an Emergency Please Notify the Following at Once to Arrange Further Details:
Name:
Relationship:
Address:
City, State, Zip:
Phone:
Are you a U. S. Veteran? Yes No
(If "Yes" please complete the following: )
Branch of Service:
Date Enlisted:
Name of War:
Date Discharged:
Service Number:
Location of Discharge Papers:

FUNERAL SERVICE DETAILS

Church Preference:
Funeral to be held at: Brust Funeral Home Church
Cemetery
(Name and location):
Grave
Section
Lot
Block
Lot is owned
in the name of:
Location of
Cemetery Deed:
If Interment is to be elsewhere, please complete:
Ship to:
Cemetery Phone:
Receiving Funeral Home:
(if needed)
Address:
City, State, Zip:
Phone:
Use an Obituary listing survivors: Yes No
Preference of Songs to be Sung or Played
Organizations and/or Activities for which I would like to be remembered:
Other Specific Directions / Preferences:
 

RELATIVES AND FRIENDS TO BE NOTIFIED
(Living Parents, Brothers and Sisters, Children, Grandchildren, etc.)

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