Warner Funeral Homes & Crematory

Funeral Preplanning

Please fill out the form below as best as you can, and we'll contact you regarding preplanning arrangements.

* - required fields

Confidential Personal Information
Your Name: *
Your Address (Street):
Your Address (Line 2):
City:
State/Provence:
Zip/Postal Code:
Phone Number:
Email Address: *
Best Time to Contact You:

Your Date of Birth: * (mm/dd/yyyy)		Social Security/Insurance Number:
Age of Spouse (if alive)		Citizen of What Country:
Occupation:		Birthplace: (city & state or provence)
Education:		Place of Business:
Father's Name:		Father's Birthplace:
Mother's Maiden Name:		Mother's Birthplace:

Benefit Information
Military Service:		Branch:
Date of Enlistment:		Date of Discharge:
Service Number:

Funeral or Memorial Service Preferences
Type:
City and State of Final Resting Place:
Clergy:
Music, Readings, Etc.
Pallbearers:
Honorary Pallbearers:
Special Requests:
Clothing, Jewelry, Etc.:
Casket/Urn:
Burial Vault:
Flowers:

Preferences for Final Disposition Family Burial Property
Location:
Number of Spaces:
Which Space:
Other: (scattering, Mausoleum, entombment, etc.)
Preferences for Memorialization:
Additional Information:

SPENCER HARTLEY SUTHERLAND PETERSON EVERLY
225 West 3rd Street • Spencer, IA 51301 • 712-262-3640 • Fax 712-262-1618

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