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Name and Age of Deceased
Residence of Deceased
Place and Time of Death (Day, Date, Time)
Services (check all that apply)
Memorial Service Location
Interment is Where:
Vigil Services/Rosary Services:
Officiated by Whom?
About the Deceased:
Date and Place of Birth
Father Living or Deceased?
Mother's Maiden Name:
Mother Living or Deceased?
Name of Spouse (include maiden name, if applicable)
Spouse Living or Deceased?
If Spouse is Deceased, Date of Death
When and Where Married?
Career Information: Give a BRIEF description of occupation, education, military or other special honors:
Other Survivors? Children's Names, Names of Spouses and Where They Live, if Applicable:
Brothers and Sisters (with spouses and where they live):
Number of Grandchildren
Number of Great-Grandchildren
Number of Great-Great-Grandchildren
Preceding in Death
Please list name and relationship to deceased
Memorials May Be Made To:
Name of Funeral Home in Charge of Services:
Name and Phone Number of Person Who May be Contacted in Case More Information is Needed: