Pre-Need Information Form

Fields with a * are required. If you do not know the answer enter the word 'Unknown'. If the field requires a number and you are unsure enter all Nines (9). Example SS#: 999-99-9999. At the time of need you will need to have the unknown information for the Death Certificate process.

Contact Person

Name*
FirstLast
Middle Name
Address*
Street AddressCityStateZIP Code
Email
Phone
Cell Phone
Work Phone
Social Security Number
Social Security Number will need to be provided at time of arrangements
Relationship to Insured*

Insured Person (Person for whom Prearrangements are for)

Name*
FirstLast
Middle Name
Sex*
Date of Birth*
Birthplace: City, State, Country*
Marital Status*
Name of Spouse (maiden name, if wife)
In Armed Forces*
Social Security Number*
Usual Occupation*
(If retired occupation prior to)
Kind of Business/Industry*
Education (highest completed) Elementary & Primary (0-12)*
Higher Education*
Address*
Street AddressCityStateZIP Code

Father

Father's Name*
FirstLast
Legal forms require this information. If you do not have this information,'Unknown' will need to be inserted.
Middle Name
Step-Father Name

Mother

Mother's Name*
FirstLast
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Middle Name
Maiden (last) Name*
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Step Mother Name

Cemetery Information

Burial/Cremation/Anatomical Study*
Organ Donor*
Cemetery Name
Location City/Location State of Cemetery

Church Information

Church Name
Denomination
Church Phone
Church Address
Street AddressCityStateZIP Code
Minister's Name
FirstLast
Minister's Phone

Family Information

Children (oldest to youngest with spouse info)

First (Spouse) Last

Grandchildren (oldest to youngest with spouse info)

First (Spouse) Last

Great Grandchildren (oldest to youngest with spouse info)

First (Spouse) Last

Siblings (oldest to youngest with spouse info)

If siblings are deceased, please type 'deceased' before the respected name.

First (Spouse) Last

Memorials

Name
FirstLast
Address
Street AddressCityStateZIP Code
Phone

Past Services Held at Hitzeman Funeral Home

Name of Deceased Relative
Date of Death
Name
FirstLast

Membership in Organizations, Clubs or Societies

Organizations, Clubs or Societies: Name & Contact Information
Use separate line for each entry.

People / Groups to Notify about Funeral Services

Name of Person / Group & Email Address
Use separate line for each entry.
How many nights would you like to have a Visitation. One or two?
- One
- two
Would you like a Funeral Service or Funeral Mass?
- Funeral Service
- Funeral Mass

What is the Name and contact information (Address, Phone and Fax if applicable) of your loved one's Primary Care Physician?

Name
FirstLast
Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Phone
Fax

Pre-Need Information Form

Contact Person

Name*

Address*

Insured Person (Person for whom Prearrangements are for)

Name*

Address*

Father

Father's Name*

Mother

Mother's Name*

Cemetery Information

Church Information

Church Address

Minister's Name

Family Information

Children (oldest to youngest with spouse info)

Grandchildren (oldest to youngest with spouse info)

Great Grandchildren (oldest to youngest with spouse info)

Siblings (oldest to youngest with spouse info)

Memorials

Name

Address

Past Services Held at Hitzeman Funeral Home

Name

Membership in Organizations, Clubs or Societies

People / Groups to Notify about Funeral Services

What is the Name and contact information (*Address, Phone and Fax if applicable*) of your loved one's Primary Care Physician?

Name

Address

What is the Name and contact information (Address, Phone and Fax if applicable) of your loved one's Primary Care Physician?