Learn About Pre-Planning

If you would like more information on the benefits of funeral pre-planning, please complete this simple form. Indicate below if you would like someone from Heil-Schuessler Funeral Home to contact you. (*)Denotes a required field.

Required Information

I am planning for:
MyselfSpouseParentOther Friend/Family

Your First Name:

Your Last Name:

Your Middle Name:

Your Street Address:

City, State, Zip:

Phone:

Your Email: (*)

Vital Information about the person you are planning for...

First Name:

Last Name:

Middle Name:

Gender:
MaleFemale

Marital Status:
SingleMarriedDivorced/SeparatedWidowed

Date of Birth:

Mother's Name:

Mother's Maiden Name:

Father's Name:

Spouse's Full Name:

Spouse's Maiden Name:

Number of Children:

Children's Names and Ages:

Military Record (If applicable)

Branch of Service:
ArmyNavyAir ForceMarinesCoast GuardArmy Air CorpsMerchant Marine

Serial Number:

Date Enlisted:

Rank at Discharge:

Date Discharged:

Discharge on file at:

Copy of discharge papers:
YesNo

Participant in these wars:

Additional Details...

Usual Occupation (most of life):

Employer:

Religious affiliation:

Place of worship:

Participation in organizations - Fraternal, Professional, Clubs, etc.:

Most interesting facts about life:

Contact Options:
Send information about Pre-arrangementContact me to set an appointmentKeep my information on file

Any other instructions or information you would like us to have:

Funeral Service information...

Name of person who will finalize arrangements at time of death (If other than the person completing this form):

Address of person finalizing arrangements :

City, State, Zip of person finalizing arrangements :

Phone of person finalizing arrangements :

Email of person finalizing arrangements :

Preferred Cemetery :

Has cemetery property been purchased?:
YesNo

Last will and testament?:
YesNo

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