Pre-Planning Form

Full Legal Name:

Street Address:

City, State, Zip Code:

City/Village or Township:

(Select one, list township if applicable)


Place of Birth:

Social Security Number:

Full Name of Next of Kin:

Mailing Address of Next of Kin:

Phone Number of Next of Kin:

Name of Power of Attorney:

Name of Personal Representative:

Name of Attorney:

Names of People to Handle Arrangements:

(Include address and phone number if different from above)

Full Name of Father:

(Include middle name)

Full Name of Mother:

(Include middle and maiden name)

Highest Level of Education:

Name of High School:

Name of College:

Marital Status:

Full Name of Spouse:

(Include maiden name)

Date of Marriage:

Place of Marriage:

Employment History:

Military Service:

(Attach copy of discharge papers)


Serial Number:
Highest Rank:


Organizations, Memberships, Hobbies, and Interests:

Names of Surviving Family Members:

(Include the name(s) of spouse/relative and your relationship to each)

Names of Family Members Preceded in Death:

(Include your relationship to each)

Place of Visitation:

Place of Funeral Service:

Church Affiliation:

Name of Clergy:

Names of Casket Bearers:

Special Services Desired:

Military Tribute Desired:

Name(s) of Special Songs Desired:

Name of Organist Desired:

Name of Soloist Desired:

Name of Hairdresser Desired:

Name(s) of Special Scriptures Desired:

Date of Your Baptism:

Date of Your Confirmation:

Confirmation Verse:

Favorite Flower(s)/Color(s):

Favorite Color(s):

Memorial Donations Designated to:

Cemetery Information:
Block Number:
Lot Number:
Space Number:

Cemetery Marker:

Veteran's Marker:

Disposition Choice:

Casket Preference:

(Wood or Metal)

Urn Preference:

Vault Preference:


Verse Inside Memorials:


Special Instructions:

Names of Newspapers for Obituary:

Funding for Irrevocable Funeral Trust:

I Chose Barbola Funeral Chapel Because:

Barbola Funeral Chapel appreciates the confidence you have placed in us.