Faith and Practice

name date

address

social security number

yes no I have completed a Durable Power of Attorney for Health Care Decisions.

yes no I have completed forms to be an organ donor A copy of my DPAHCD and/or organ donor form is located:

I request that the Society of Friends carry out the following upon my death:

The information below may help the Society of Friends carry out my wishes.

1. Persons to notify immediately (next of kin, executor etc.):
name phone number
address relationship
name phone number
address relationship

2. Member of Memorial Society
address
telephone
location of contract

3. Disposal of body
burial cremation medical research
Preferred site for disposal of ashes:
Cemetery preferred: common plot family plot
location of deed
location of release papers
undertaker preferred

4. Burial insurance
insurance company
policy number
If no insurance, the expenses will be met as follows:

5. Services desired, and who should conduct the services:

Memorial Meeting for Worship Special Requests:

6. Flowers will be accepted
where
in lieu of flowers, contributions may be made to

7. Special instructions if death is distant from home:

8. My will and/or other legal documents are located:

 

9. If no surviving parents, instructions on care of minor children (over)

10.Information for death certificate (must agree with legal records and policies)
full legal name
present address
date of birth birthplace citizenship
occupation present employer
title address
fathers full name mothers maiden name

received for meeting date

signature