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:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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