Scales and Sons Funeral Home

Personal Information
Name (First MI Last):
Marital Status:		Social Security#:
Date of Birth:		Place Of Birth:
Address:
City:		State:
County:		Zip:
Phone:		E-mail:
Spouse's Name:		Spouse's Maiden Name:
Place of Marriage:		Date of Marriage:
Father's Name:		Mother's Name:
Mother's Maiden Name:

Work/Education History
Education(0-12):		College 1-5+:
Occupation:
Business:		Company:

Military Record
Branch of Service:		Serial Number:
Date Enlisted:		Rank At Discharge:
Date Discharged:		Discharge On File At:
Copy of Discharge Papers: Yes No
Name Of Wars:
Person in Charge:
Address:
Phone:
Insurance Information:

Funeral Service Request
Place Of Service:
Funeral Home:
Address:		Phone:
Place of Visitation:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person in Charge of Final Arrangements:

Special Instructions
Flower Preference:
Music
Casket Bearers (6):
Jewelry:
Glasses:
Clothing:
Other:

Disposition Request
I Prefer:
Cemetery:
Address:		Phone:
Section:
I have made a last will and testament: Yes No
Location:

Other Instructions

Memorials/Donations To Charity

Please select one of the options below
Send information about pre-arrangement Contact me to set an appointment Please keep my information on file