Online Planning Form | Massapequa Funeral Home

Information About the Person Completing This Form

I am planning for*

Your Name*

First Last

Middle

Phone*

Email*

Address

Street Address Address Line 2 City State ZIP Code

County

Show Detailed Form?

Yes
No

Information About the Person For Whom You Are Planning

Name

First Last

Middle

Gender

Marital Status

Date of Birth

MM

DD

YYYY

Place of Birth

Spouse's Full Name

Spouse's Maiden Name

Place of Marriage

Date of Marriage

MM

DD

YYYY

Mother's Name

Mother's Maiden Name

Father's Name

Work and Education

Education (Primary)

Years Attended

College (1-5+)

Years Attended

Usual Occupation (most of life)

Kind of Business

Company

Military Records

Branch of Service

Serial Number

Dishcharge on file at

Date of Dishcarge

MM

DD

YYYY

Rank at Discharge

Copy of Discharge

Yes
No

Names of War(s)/Conflict(s) Toured

Funeral or Memorial Service Preferences

Place of Service

Name of Funeral Home

Address

Phone

Place of Visitation

I prefer the funeral service to be

Viewing of Family

Yes
No

Viewing of Friends

Yes
No

Religious Denomination

Place of Worship

Lodge/Union

Person(s) to Finalize Arrangements at Time of Death

Full Name

Street Address

City

State

Zip

Phone

Special Instructions

Flower Preference

Music

1.

2.

3.

4.

5.

6.

Jewelry

Glasses

Clothing

Other

Disposition Options

I prefer

Cemetery

Address

Phone

Section

I have made a Last Will and Testament

Other Information and Special Instructions

Please list any other instructions you would like us to have

Memorials and Charities

Please list any memorials or donations that you would like

Contact Options

Any Questions?

Contact me to set an appointment
Please keep my information on file

Phone

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