L O A D I N G

Pre-Arrangements Form

Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form.

PERSONAL INFORMATION

Full Name *

Street

City

State/Province

ZIP/Postcode *

Telephone

Email Address *

Date of Birth

Place of Birth

SSN #

Father's Name

Father's Place of Birth

Mother's Name

Mother's Place of Birth

Mother's Maiden Name

Marital Status

Spouse's Name

Spouse's Maiden Name

Place of Marriage

Date of Marriage

Additional Family Members

Please use the area above to enter the names of siblings, children and grandchildren.

WORK/EDUCATION HISTORY

Education Level
Grade SchoolHigh SchoolDegreeMasters DegreeDoctorate
Occupation

Company Name

Business Field

MILITARY RECORD

Did you serve in the military?
YesNo

Branch of Service

Serial Number

Date Entered Service

Rank at Discharge

Date Discharged

Discharge on file at

Do you have a copy of your discharge papers?
YesNo
Wars Fought In

Person in Charge

Person in Charge Address

Person in Charge Telephone

FUNERAL SERVICE REQUEST

Place of Service

Place of Service Telephone

Place of Visitation

Religious Denomination

Place of Worship

Lodge/Union/Assoc. Membership

Person in charge of final arrangements

DISPOSITION REQUEST

I Prefer

Cemetery

Lot #

Section/Letter

Grave #

Cemetery Address

Cemetery Telephone

I have made a last will and testament
YesNo
Location of Will

SUMMARY DETAILS

Additional instructions for us

Memorial requests or donations to charity

Please select from one of the options below:
Send me information about pre-arrangementsContact me to set up an appointmentNo appointment needed just keep my request and information on file

Graham

1-336-227-2711

1030 S Main Street | Graham, NC 27253

john@mcclurefuneralservice.com

Mebane

1-919-563-3561

1308 South Third Street | Mebane, NC 27302

tmoore8878@yahoo.com