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Pre-Arrangement Forms




These forms may be downloaded, printed, filled out, and kept with your important papers. They can be updated or revised if circumstances or your wishes change. If you wish, return a copy to CAFA. You'll receive a laminated wallet-size card giving our 24-hour phone number and indicating your final wishes are on file. For additional copies or other information, call CAFA at 410-321-1005.


Contents:

  • Cremation authorization
  • Personal history
  • Funeral arrangements
  • Information for executor


    ADVANCE DIRECTIVE AND AUTHORIZATION FOR CREMATION


    I, the undersigned, do hereby authorize and request Cremation and Funeral Alternatives Stephen D. Lohrmann P.A. ("CAFA"), or its assigns, upon my death, to cremate the human remains of myself, ______________________________________________________________,
                                                      (print your full name)
    and further, I hereby agree to indemnify and hold CAFA, its officers, agents, and employees harmless from all claims, suits, or causes of action, including reasonable attorney's fees for the defense thereof, brought by any person, firm or corporation, or the personal representative thereof, arising out of this request for cremation.
    ______________________________ ______________________________
    ______________________________ ______________________________
    ______________________________ ______________________________
    (Your Signature & Address)                    (Witness's Signature & Address)
    _________________________________________________
            (Your Driver's License Number, for identification)


    NOTE: If you are completing this form for someone who has given you power of attorney, sign the incapacitated person's name and your own, e.g.: "John Doe by Mary Doe, attorney in fact." Please supply CAFA with a copy of the power of attorney.



    PERSONAL HISTORY

    Date ______________________________


    Full name ______________________________
    Maiden name ______________________________
    Street address ______________________________
    City ______________________________
    County ______________________________
    State ______________________________
    Zip Code ______________________________
    Social Security number ______________________________
    Date of birth ______________________________
    Place of birth (city and state) ______________________________
    Father's name and birthplace ______________________________
    Mother's maiden name and birthplace ______________________________
    Marital status (single, married, widowed, or divorced) _____________________
    Date and place of marriage ______________________________
    Major places and number of years of residence:
    Locally
    ____________________________________________________________
    ____________________________________________________________
    Elsewhere
    ____________________________________________________________
    ____________________________________________________________


    List the names and (if living) addresses and phone numbers of:
    Spouse ____________________________________________________________
    Any previous spouses
    ____________________________________________________________
    ____________________________________________________________
    Parents
    ____________________________________________________________
    ____________________________________________________________
    Brothers/sisters
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    Children
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    Closest friends
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    Schools attended, including dates and degrees received:
    High school ______________________________
    College ______________________________
    Other ______________________________


    Veteran information:
    Date and place of entry into active service ______________________________
    Date and place of discharge ______________________________
    Rank and serial number ______________________________
    Branch of service, organization or outfit ______________________________
    Medals or special service ______________________________
    Location of discharge papers ______________________________


    Work experience:
    Usual occupation ______________________________
    Kind of business ______________________________
    Present (if retired, last) employer ______________________________
    From (date)_______________________ to ________________________
    Job title ______________________________
    Supervisor ______________________________
    Previous employers ______________________________
    ______________________________
    ______________________________


    Affiliations:
    Religion ______________________ Church ___________________________
    Professional or fraternal organizations
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    Other organizations/special interests
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    Special awards, accomplishments, civic and fraternal positions or contributions
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    Additional information/remarks
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    I wish to have a death notice or obituary in the following publications:
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    A few personal thoughts for my family and friends:
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    FUNERAL ARRANGEMENTS


    Today's Date ______________ Your Name ____________________________


    Anatomical and disposition information:
    I do____ do not____ have an organ donor card.
    Upon my death, I wish to donate the organs checked below:
    _____Heart _____Lungs _____Kidneys _____Liver
    _____Skin _____Bone _____Cornea
    If not required, I will____ will not_____ permit an autopsy.
    I do____ do not ____ wish for my body to be embalmed.


    Upon my death, I wish for my body to be:
    _____cremated
    _____buried
    _____entombed
    _____donated to medicine. Preferred institution: ___________________________________________.


    I have made funeral pre-arrangements with:
    Funeral establishment ______________________________
    Phone ______________________________
    I have not made funeral pre-arrangements, but I prefer that this firm be used:
    ____________________________________________________________


    I have not purchased cemetery space, but I prefer that this cemetery be used:
    ____________________________________________________________


    CEREMONY PREFERENCES:
    I do______ do not_____ wish to have a visitation.
    _____Public ______Private visitation. Casket ______open _____closed
    Visitation location and time ______________________________


    I would like:
    _____ a traditional funeral, with a graveside service
    _____ a traditional funeral, without a graveside service
    _____ a graveside-only service
    _____ a memorial service (without the body present)
    _____ other:_______________________________
    _____ no service


    These are my preferences/suggestions for:
    Location of service ______________________________
    Clergy/officiate ______________________________
    Special music ______________________________
    Organist/soloist/other ______________________________
    People to speak ______________________________
    Scriptures/poems/other to be read ____________________________________________________________
    ____________________________________________________________
    Flowers ______________________________
    Memorial donations made to ______________________________
    ______________________________
    Photographs or possessions to be displayed ____________________________________________________________


    For cremation:
    Casket or cremation container I prefer ______________________________
    Please remove all jewelry before cremation and return to ______________________________
    Cremation remains _____should ____should not be present at service.
    I would like my ashes _____buried _____scattered. Location: ______________________________
    I wish my cremation remains returned to (name)______________________________


    For burial or entombment:
    Casket should be _____open _____closed at the funeral.
    Casket I prefer ______________________________
    Outer enclosure (vault) I prefer ______________________________
    Cemetery name ______________________________
    Section ________ Lot ________ Space _______
    Clothing to use ______________________________
    Jewelry I wish to wear ______________________________
    Instructions for disposal of jewelry before burial ______________________________


    Pallbearers I would like ____________________________________________________________
    ____________________________________________________________


    Honorary pallbearers ____________________________________________________________


    Any additional instructions or considerations:
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    INFORMATION FOR MY EXECUTOR


    Locations of documents/property:
    Will/Advance directives ______________________________
    Pre-need funeral contract ______________________________
    Cemetery deed ______________________________
    Safe deposit box key ______________________________
    Birth certificate/Marriage license ______________________________
    Mortgages and notes ______________________________
    Deeds and titles ______________________________
    Insurance policies ______________________________
    Income tax records ______________________________
    Stocks and bonds ______________________________
    Pension plan ______________________________
    Social Security/Veteran's papers ______________________________
    Checkbooks and passbooks ______________________________
    Other important papers/property ______________________________


    Names and phone numbers of professionals/companies:
    Physician ____________________________________________________________
    Lawyer ____________________________________________________________
    Accountant ____________________________________________________________
    Brokers ____________________________________________________________
    Insurance agents ____________________________________________________________
    Banks ____________________________________________________________
    Others ____________________________________________________________
    Credit cards and charge accounts to be canceled:
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________


    2007 Cremation and Funeral Alternatives Stephen D. Lohrmann P.A. All rights reserved.


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