James A. Reed Funeral Home

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Please fill in as much information as you can.

Required Information

I am planning for:myself
spouse
parent
other friend/family
Your first name:
Your last name:
Your middle name:
Your street address:
City, State, Zip:
County:
Phone:
Email:

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

First name:
Last name:
Middle name:
Gender:male
female
Marital status:single
married
divorced/separated
widowed
Date of birth:
Place 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,ages:

Military record (if applicable)...

Branch of service:Army
Navy
Air Force
Marines
Coast Guard
Army Air Corps
Merchant Marine
Serial number:
Date enlisted:
Rank at discharge:
Date discharged:
Discharge on file at:
Copy of discharge papers:yes
no
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 fact about life:
Contact Options:send information about pre-arrangement
contact me to set an appointment
keep my information on file
Any other instructions or information you would like us to have:

Funeral Service information...

Who will finalize arrangements at time of death?
Same person completing this form?yes
If other,
Full name:
Street address:
City,State,Zip:
Phone:
Email:
Preferred cemetery:
Has cemetery property been purchased?yes
no
Last will and testament:yes
no
Verification

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137 Market St • Pillow, PA 17080

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