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1455 Mansion Drive / P.O. Box 86 / Monroe, Wisconsin 53566 / Tel: 608-325-4306 / FAX 608-325-2185
PLEASE NOTE:
To fill out this form click on each white box as you come to it and begin typing. Then
click inside the next white box you want to type in. When you are finished, at the
bottom, click on the "submit" button to send in the form.
Complete only those items you wish to pre-arrange. Keep these instructions in an accessible
place (not your bank safe deposit box). If you wish, Shriner-Hager-Gohlke Funeral home will
keep these instructions in our confidential files. Tell whoever will be responsible for your
personal affairs where this record is kept. Update this record as time passes so this information is current, as it is used for official documents.
___________________________________________________________________________________________________________________________
VITAL STATISTICAL & BIOGRAPHICAL INFORMATION
Full Name:
Address:
Birthplace: Birthdate:
Hobbies, Sports, Favorite Activities, Noted For:
Came to U.S.A. Settled Where:
Schooling
Length of Residence Here Coming From
Lived Previously
Usual Occupation Employer Retired
Maiden Name
Father's Name
Social Security # If Veteran, War Dates
Church preference or Member of
Clergy preference
Cemetery
Addition Section Block Lot Grave
FUNERAL INSTRUCTIONS
Place of Services Visitation
Please Specify: Burial Entombment Cremation
Affiliations (Clubs, Organizations, Lodges, Public Office
Mother's Maiden Name
Date Married Where To Whom
Type of Casket Desired
Burial Vault/Urn Desired
PERSONAL REQUESTS: Memorial Fund For
Lodge Services
Military Rites
Songs
Soloist/Duet
Organist
SPECIAL INSTRUCTIONS
Clothing
Hair Dresser Attorney
Newspapers Picture
Other
LIVING RELATIVES
Relationship
(Husband/Wife, Children,
Parents, Brothers, Sisters) Full Name City and State
Number of Grandchildren
Number of Great Grandchildren
Number of Great-Great-Grandchildren
DECEASED RELATIVES
Relationship
(Husband/Wife, Children,
Parents, Brothers, Sisters) Name City and State
BEARERS
Name City and State Tel. Number
Alternates:
This information is for guidance at the time of my death. It is intended to assist those handling
my personal affairs. I have expressed my preferences on certain subjects which, unless changed
by unforseen circumstances, I hereby desire and request.
Signature
Full Name Age
Address
Day/Date of Death Where
Date of Birth Where
Name of Parents
Schooling
Married Whom
Married When and Where
Occupation: Where lived or worked
Member of Church, Lodge, Organization; or held public office
Military Record
Names & locations of survivors (husband or wife)
(Parents)
(Sons)
(Daughters)
(Brothers)
(Sisters)
Number of Grandchildren Number of Great-grandchildren
Predeceased by
Funeral Time, Day/Date & Place
Clergy/Officiant
Cemetery & Location
VISITATION time, day/date & place
Memorial fund
Lodge Services, Rosary
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