Pellerin Funeral Homes

Personal Information

First Name:
Middle Name:
Last Name:
Date of Birth:
Birthplace:
Address:
City:
State/Province:
Zip/Postal Code:
Race:
Marital Status:

Father's Name:
Place of Birth:
State:
If Living/City of Residence:
State/Province:
Zip/Postal Code:

Mother's Maiden Name:
Place of Birth:
State:
If Living/City of Residence:
State/Province:
Zip/Postal Code:

Where was deceased raised?

Highest level of education:

Maiden Name of Spouse:
Date of Marriage:
Place:
If deceased, date of death:

Where has deceased lived during his/her adult life?

Name of children & their spouses, and their addresses

Child#1 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#2 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#3 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#4 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#5 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Current Number of Grandchildren:
Current Number of Great Grandchildren:

Names of surviving brothers & sisters and their addresses

Sibling#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Preceded in death by

Occupation. Give the type of work done most of working life, even if retired.

Name of Employer:

If Retired, Date of Retirement:
Total years spent in your occupation:

Church affiliation & activities:

Did deceased serve in the military? Yes No

If yes, what branch:

Service #, War, Date of Entry, & Date of Discharge:

Civic & Professional Organizations:

FUNERAL INSTRUCTIONS

Place of Service:

Minister:

Music Selections:

Organist:

Singer(s):

Singer#1:

Singer#2:

Singer#3:

Singer#4:

Singer#5:

Pallbearers:

Pallbearer#1:

Pallbearer#2:

Pallbearer#3:

Pallbearer#4:

Pallbearer#5:

Pallbearer#6:

Pallbearer#7:

Pallbearer#8:

Favorite Bible Selections:

Special Services (Military or Lodge)

Cemetery Information

Name of Cemetery:
Location City:
Lot is in the name of:
Section:
Lot:
Grave Space:

Casket and Burial Preferences

Casket:
Metal:
Wood:
Exterior Color:
Interior:
Burial Vault:

Authorized Persons to Arrange Final Details

Person#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Special Instructions