111 Wolcott St.
P.O. Box 37
Le Roy, NY 14482
Phone: (585) 768-6800
Fax: (585) 768-7072
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Immediate Need

I. Biographical Information
 
Full Name:
Date of Death:
Address1:
Address2:
City Name:
State:
Zip Code:
Telephone Number: (xxx-xxx-xxxx)
Email Address:
Date of Birth: (month/day/year)
City of Birth:
State of Birth:
Highest Education Level:
Please select Grade/Years of Education completed:
   
Social Security Number: For security reasons, we will contact you to complete the pre-arrangement.
Residence History:
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:

II. Military Record

Veteran:
Branch of Service:
Serial Number:
Date Enlisted: (month/day/year)
Date of Discharge: (month/day/year)
Rank at Discharge:
Location of a Copy of Discharge (DD214):
Time of Military Service:
Military Honors at Graveside:
Flag Preference for Service:

III. Service Preferences

Type of Service:
Visitation Hours:
Casket:
Person in Charge of Arrangements:
Officiating Clergy:
Pallbearers:
Flower Preference:
Music Selection:
Jewelry:
Glasses:
Casket Preference:
Disposition:
Outer Container Preference: (for ground burial)
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

 

 

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