Potter Funeral Service - Funeral Pre-Arrangement Form

To begin the arrangement process, please fill out the form below. *Required

Funeral Being Planned For: Funeral Being Planned For: First Middle Last
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone: Phone: - ### - ### ####
Email:
Date of Birth: Date of Birth: / MM / DD YYYY
Place of Birth:
Marital Status:
Spouse's Name: Spouse's Name: First Last
Father's Name: Father's Name: First Last
Father's Birth Place:
Mothers's Name: Mothers's Name: First Last
Mother's Birth Place:
Mother's Maiden Name:
What is your race?:
Years Of Education:
Occupation:
Employer:
Military Veteran:

Military Veteran: Yes No
Branch of Service:
Serial Number:
Date Enlisted: Date Enlisted: / MM / DD YYYY
Rank at Discharge:
Date Discharged: Date Discharged: / MM / DD YYYY
Discharge on File at:
Copy of Discharge Papers:

Copy of Discharge Papers: Yes No
Person in Charge of Final Arrangements:
Person in Charge of Final Arrangements Relationship:
Person in Charge of Final Arrangements Mailing Address: Person in Charge of Final Arrangements Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Person in Charge of Final Arrangements Phone: Person in Charge of Final Arrangements Phone: - ### - ### ####
Person in Charge of Final Arrangements Email:
List Children and Their Spouses:
Please List Brothers:
Please List Sisters:
Please List Grandchildren:
Please List Great Grandchildren:
Disposition Requested:
Cemetery Section:

If Known
Funeral Home Location:
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Please fill in these numbers with no spaces. 4 5 8 2