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NAME________________________________________________________________
SEX_____
DATE OF BIRTH ___/___/___ PLACE OF BIRTH______________________________________
SPOUSE (MAIDEN)___________________________________________ SURVIVING
(Y/N)___
SOCIAL SECURITY # _________________________________________
VETERAN (Y/N)____ HONORS DESIRED (Y/N)____ MARITAL STATUS__________________
PRIMARY EMPLOYMENT RESIDENCE
USUAL OCCUPATION___________________________ BUSINESS________________________
EMPLOYER___________________________________ LENGTH_______ RETIRED (Y/N)______
STATE_______________________ COUNTY________________ CITY______________________
EDUCATION
ELEMENTARY/SECONDARY (0-12)___ COLLEGE (1-4 OR 5+)____
HIGH SCHOOL____________________ COLLEGE___________________________________
DEGREES____________________________________________________________________
PARENTS
FATHER__________________________________________________ SURVIVING (Y/N)____
MOTHER (MAIDEN)________________________________________ SURVIVING (Y/N)____
MILITARY
BRANCH_______________________________ UNIT__________________________________
SERVICE NUMBER______________________ WAR_________________________________
ENLISTED DATE_______/______/______ DISCHARGE DATE ________/________/________
ACTIVITIES
CHURCH AFFILIATION__________________________________________________________
ORGANIZATIONS______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
CONTRIBUTIONS______________________________________________________________
PREPARATION
HAIR STYLING_________________________________________________________________
FUNERAL
____FUNERAL HOME CHAPEL ____CHURCH ____OTHER________________________________
OFFICIATING__________________________________
DISPOSITION
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___BURIAL |
___CREMATION |
___REMOVAL FROM STATE |
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__DONATION |
___OTHER (SPECIFY)_____________________________
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PLACE OF DISPOSITION____________________________________________ |
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NAME OF CEMETERY, CREMATORY, ETC. |
BURIAL
LOCATION___________________________________________________________________
CITY________________________ STATE________________________ ZIP______________
SECTION___ ROW____ LOT____ SPACE____
Preneed or Pre-arranged
Information:
Please FAX John Kazlauskas at FAX 508-793-1939
HENRY-DIRSA
FUNERAL SERVICE
33 Ward St.
Worcester, MA 01610
508-756-8346
E-mail
Us
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