Dain Cullinan Funeral Home Inc.

Your Full Name:
Your Maiden Name:
Street/Mailing Address:
Date of Birth:
Place of Birth:
Social Security Number:
Marital Status:
Date of Marriage:
Place of Marriage:
Names of Previous Spouses:
Names of Parents:
Address of Parents (if still living):
Names of Children:
Addresses and Phone numbers of Children:
Names of Brothers and Sisters:
Addresses and Phone numbers of Brothers and Sisters:
Names of other friends and relatives who should be notified:
Addresses and Phone numbers of other friends and relatives:
Names of present and previous employers:
Addresses and Phone numbers of present and previous employers:
If you are a veteran
Date of enlistment:
Place of enlistment:
Date of discharge:
Place of discharge:
Rank:
Service Numbers:
Organization or outfit:
Commendations received:
Location of discharge papers:
Flag desired to drape casket:

Religious affiliation:
Professional and fraternal organization memberships:
Education (list schools attended and dates of any degrees or honors received):
Names of newspapers for obituary:
Organ Donation (list of authorized card and anyone who should be notified):
Funeral director or funeral home you prefer:
Clergyperson or anyone else you would like to officiate:
Funeral Service Location:
Visitation instructions:
Music, hymns or readings you would prefer during your service:
Memorial Donations you would like in your memory:
Names and Addresses and Phone Numbers of casket bearers:
Address and location of cemetery property (include lot and grave number):
Casket and/or vault preference:
If you wish to be cremated, include disposition preference:
Location of will:
The name of the executor of your estate:
Address and phone number of the executor of your estate:
Location of safety deposit box and key:
Attorney's name:
Attorney's address and phone number:
Location of checking accounts, checkbooks, savings accounts and passbooks:
Credit cards and charge accounts to be canceled. ( for security purposes do not list Credit Card Numbers here, just the names of cards.)
Insurance company name and policy numbers:
Location of insurance policies:
Any additional instructions: