This form is provided as a service to allow the individual to record their funeral preferences. If you are not comfortable with sending this information in an e-mail message, please feel free to contact James H. Davis Funeral Home directly or print this page and place it in a safe location or mail to us.

Personal Information :

Name:   Male Female Single Married Separated Divorced Widow Widower

Date of Birth:     Place of Birth:

Address:

City:   

State:   Zip:

County:  

Years in County:   State of Birth:

Social Security Number:

Spouse's Name:   

Spouse's Maiden Name: 

Work / Education History :

Education Level: N/A K-6 grade 6-9 grade 9-12 grade Bachelor's Master's Phd

Occupation:     Business:

Company:     Number of Years:

Military Service :

Service Branch:    

Serial Number:

Date Enlisted:   

Rank at Discharge:

Date Discharged:    

Discharge on file at:

Name of Wars: 

Funeral Preferences :

I prefer my Funeral Service to be:   Public Private   

Place of Service:   Chapel Church Cemetary None Other

Conclude Service at:   Funeral Home Graveside Church Reception

Religious Denomination:

Place of Worship:     Priest Elder Clergyman Rabbi Reader

Name:    Type of Clothing:  My Own New

Memorialization Instructions :

Musical Selections to be played: 
1.
2.
3.

Will Supply CD / Tape

Musical Selections to be sung:  
1.
2.

Favorite Bible Passages:

Favorite Literature or Poems: 

Favorite Flowers: 

Favorite Flower Color: 

Final Disposition :

Preference for final disposition is:

Ground interment with   Vault Concrete Linear Burial Vault

Mausoleum entombment  

Cremation with   Burial Niche_entombment Home memorialization Scattering

Preference of cemetery or mausoleum:

Address: 

A   Cemetery Plot Crypt Niche None   is owned at the above location.

Special Instructions:  

Person to Finalize Arrangements at Time of Death :

Name:   Relationship:

Address:         

City:   State:     Zip:

Phone:     

Fax:    E-mail: