OBITUARY CHECKLIST

Name:

Name at Birth:

Date of Birth:

Gender:

Social Security Number:

Occupation:

Type of Business/Industry:

Residence Address:

City:

State:

Zip Code:

Birthplace:

Marital Status:

Surviving Spouse (Maiden Name):

Ancestry:

Race:

Hispanic Origin:

U.S. Armed Forces Member:

Branch of Service:

Do you have a DD214 form available to provide:

Yes

No

Highest Education:

Father's Name:

Mother's Name

Mother's Maiden Name:

Informant's Name:

Relationship:

Informant Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email

Preferred Service Type:

Type of Disposition:

Do you want an Obituary?

Published in the Newspaper?

Published on Social Media (Website, Facebook etc.)?

Do you want a photo to accompany the Obituary?

Obituary:

Do you have any Personal Preferences?

Interests/ Hobbies:

Love Note:

Passions and Dreams:

Legacy:

Favorite Memories:

Favorites:

Favorite Music:

Favorite Quote, Psalm, Scripture:

Preceded in Death:

Survivors:

Attach Photo

309-798-9798

Mississippi Valley Cremation & Direct Burial

1811 15th Street Place

Moline IL 61265

Email: info@mvcremation.com

Share by: