Pre-Planning Form

Shook Funeral Home
639 Van Houten Avenue
Clifton, NJ 07013
973-471-9620

I am planning for:
---------------Personal Information---------------
Name:
Email Address:
Address:
City:
State/Province:
Zip Code:
Phone Number:
Place of Birth:
Date of Birth:
Sex:
Citizenship:
Marital Status:
Spouse (Maiden Name):
Father's Name:
Mother's Maiden Name:
SSN:
Religous Preference:
---------------Education---------------
High School Name:
# of Years:
College Name:
# of Years::
---------------Family Information--------------- Please list the names of survivors and state their relationship to you, their spouse's names and the city in which they live as you wish to have them listed in the memorial. (The following is a guide to assist you.) SURVIVORS: Spouse, Sons, Daughters, Parents, Brothers, Sisters, Grandchildren, (Great-grandchildren), Grandparents, Others (Eg. Son: Joe Smith and his wife Paula of Milledgeville)
Survivors:
Preceded in Death by:
Additional Information and Organizations:
---------------Work History---------------
Occupation:
Business:
Industry:
Company:
Number of Years:
Years Retired:
---------------Military Service---------------
Service Branch:
Serial Number:
Date Enlisted:
Rank at Discharge:
Date Discharged:
Discharge on File At:
Combat Action:
---------------Funeral Preferences---------------
I prefer my Funeral Service to be
Public:
Private:
---------------Visitation---------------
Public:
Private:
Place of Service:
Other:
I prefer:
Burial:
Entombment:
Cremation:
I would like to be contacted to discuss these arrangements further::

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