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Vital Information
Full Name:
Date of Death:
Address:
Telephone Number:
Email Address:
Date of Birth:
City and Province of Birth:
Father's Name:
Father's City of Residence:
Mother's Name:
Mother's City of Residence:
Mother's Maiden Name:
Spouse's Name:
Spouse's Maiden Name:
Survivors' Names and Cities of Residence:
Relatives Who Have Preceded In Death:
Occupation:
Business Type:
Company Name:
Church Membership:
Lodge or Union Name:
Veteran:
Yes
No
Branch of Service:
Army
Navy
Air Force
Marines
Coast Guard
National Guard
Serial Number:
Date Enlisted:
Date of Discharge:
Rank at Discharge:
Location of a Copy of Discharge (DD214):
Time of Military Service:
Not a Veteran
Peacetime
World War I
World War II
Korean War
Vietnam War
Persian Gulf War
Military Honors at Graveside:
Not a Veteran
Yes
No
Flag Preference for Service:
None
Drape Casket with Flag
Folded Flag on Casket
Type of Service:
Chapel Service
Church
Graveside
None
Visitation Hours:
Day
Night
None
Casket:
Open for Service
Closed for Service
No Public Viewing
Person in Charge of Arrangements:
Officiating Clergy:
Pallbearers:
Flower Preference:
Music Selection:
Jewelry:
No Jewelry
Give to Family
Leave Jewelry On
Glasses:
No Glasses
Donate to Lions Club
Leave On
Give to Family
Casket Preference:
Bronze
Copper
Stainless Steel
Mahogany
Walnut
Cherry
Maple
Poplar
Pine
Fiberboard / Veneer
Minimum Metal
Disposition:
Ground Burial
Mausoleum
Cremation
Outer Container Preference (for ground burial):
Bronze Triune
Copper Triune
Cameo Rose
SST Triune
Veteran
Venetian
Continental
Monticello
Minimum Grave Liner
Cemetery Name:
Cemetery Location:
The Cemetery Property is in the Name of:
Miscellaneous Notes and Instructions:
Please select one of the options below:
Please send me information
Please contact me to schedule an appointment
Please place my information on file
Thank you for your submission.
We will get back to you as soon as possible
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573-636-5533
915 Madison Street
Jefferson City
MO
65101
Fax:
573-636-7513
info@freemanmortuary.com
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