A STATEMENT OF MY WISHES IN THE EVENT OF MY DEATH

Date: ________________________

Name: _________________________________________________________________
first middle maiden last
Address: _______________________________________________________________

_______________________________________________________________

I. I would like the following person (s) to be in charge of the arrangements at the
time of my death:

1st choice: _________________________________Telephone: _________________________

Address: __________________________________ e-mail: ____________________________

2nd choice: _________________________________Telephone: _________________________

Address: __________________________________ e-mail: ____________________________

II. I would like the following person (s) to be notified:

Name: ___________________________________Telephone: __________________________

Address: __________________________________ e-mail: ____________________________

Name: ___________________________________Telephone: __________________________

Address: __________________________________ e-mail: ____________________________

Name: ___________________________________Telephone: __________________________

Address: __________________________________ e-mail: ____________________________

Name: ___________________________________Telephone: __________________________

Address: __________________________________ e-mail: ____________________________

Name: ___________________________________Telephone: __________________________

Address: __________________________________ e-mail: ____________________________

Name: ___________________________________Telephone: __________________________

Address: __________________________________ e-mail: ____________________________

Date of birth: __________________ Place of Birth: _____________________________

Citizenship: ____________________Occupation: _______________________________

________ never married _________Married __________Widowed _________ Divorced

Full name of spouse: ______________________________________________________

Significant other: _________________________________________________________

Mother’s full name: _______________________________________________________

Father’s full name: ________________________________________________________

IV. My preference (if any) for a funeral director: _____________________________

_______ (a) a service with the casket present followed by a burial

_______ (b) immediate burial followed by a service

_______ (c) a service with the casket present followed by cremation

_______ (d) immediate cremation followed by a service

_______ (e) _____________________________________________________________

The service to be held: at the church ___________ at the funeral home ___________

The following persons to serve as pallbearers:

Name: ________________________________ Address: _____________________________

Name: ________________________________ Address: _____________________________

Name: ________________________________ Address: _____________________________

Name: ________________________________ Address: _____________________________

Name: ________________________________ Address: _____________________________

Name: ________________________________ Address: _____________________________

Embalming to be omitted if possible: __________ yes _________ no

The casket to be: _______ inexpensive _______ modestly expensive _______expensive

I wish to be buried in: __________________________________________________________

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A viewing to be omitted: YES _______________ NO ______________

V. In lieu of flowers (yes _____ no _____) I would like memorial gifts to be made to:

________ (a) ____________________________________________________________

________ (b) ____________________________________________________________

________ (c) ____________________________________________________________

VI. In case of burial (of casket or ashes):

Cemetery: ____________________________Location: _____________________

VII. In case of cremation, I would like my ashes to be:

________ buried in the cemetery named above ________ disposed of by the crematory.

Other: __________________________________________________________________

VIII. My body or specified parts of it is to be donated for medical purposes:

________ Yes ________ No

Primary Care Provider’s name: ______________________________________________

Telephone: ___________________ Address: ___________________________________

Donations to be made:

(a) __________________________________________________________________

(b) __________________________________________________________________

(c) __________________________________________________________________

IX. In case of terminal illness I request that I be allowed to die without extraordinary

measures are taken to keep my body functioning: Yes __________ No __________

X. A post-mortem examination may be made if useful for medical knowledge and

requested by the hospital or attending primary care provider. Yes __________ No __________

XI. Minor children for whom, in the event of their deaths, I wish arrangements similar to
my own.

Name: ___________________________________________________________

Place of birth: ______________________________ Date of birth: ____________

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 Name: ___________________________________________________________

Place of birth: ______________________________ Date of birth: ____________

Name: ___________________________________________________________

Place of birth: ______________________________ Date of birth: ____________

Name: ___________________________________________________________

Place of birth: ______________________________ Date of birth: ____________

XII. Legal and financial information:

location of my safe deposit box (es) and keys: _______________________________

_____________________________________________________________________

location of my Will and other important papers: ______________________________

_____________________________________________________________________

My Executor/ Executrix: Name: ___________________________________________

Address: _________________________________ Telephone: __________________

Social Security #: ____________________________ Location of card: ______________

Military Serial #: _______________________ Location of discharge papers: __________

XIII. A brief biographical sketch which can be used for an obituary is enclosed.

Yes ________ No ________

I HEREBY REQUEST MY SURVIVORS TO CARRY OUT THE WISHES I HAVE

Signature: ______________________________________ Date: _________________

Witness: ______________________________________________________________

Address: ______________________________________________________________

Distribution:

A. Retain one copy, and give copies to persons named in paragraph I.

B. DO NOT PLACE IN SAFE DEPOSIT BOX; document must be readily accessible at

C. Give a copy to the funeral director, if one has been named.

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 LOCATION OF IMPORTANT PAPERS

1. Birth Certificate: ________________________________________________

2. Marriage certificate: _____________________________________________

3. Baptismal certificate: ____________________________________________

4. Social Security Card: _____________________________________________

5. Military Discharge: ______________________________________________

6. Insurance Policies: _______________________________________________

Account #: _____________________ Issued by: _______________________

Account #: _____________________ Issued by: _______________________

Account #: _____________________ Issued by: ________________________

7. Stocks & Bonds: __________________________________________________

8. Deeds to Property: _________________________________________________

9. Title Papers for car: _________________________________________________

10. Bank Accounts – Checking: __________________________________________

Savings: __________________________________________

11. Will: ____________________________________________________________

12. Others: __________________________________________________________