Brust Funeral Home - Vital Statistics Form

VITAL STATISTICS INFORMATION FOR A PREPLANNED FUNERAL AT BRUST FUNERAL HOME

You can open a funeral planning file without charge by completing the following information and forwarding it to Brust Funeral Home. You can print and mail this form or send it via e-mail.

Name:
Email Address
Address:
County:
City, State, Zip:
Phone:
Date of Birth:
Birthplace:
Marital Status:	Single Married Widowed Divorced
Name of Spouse:
Maiden Name:
Sex:	Male Female
Social Security #:
Usual Occupation:
Kind of Business or Industry:
Education Highest Grade Completed:	Less Than High School 0-12 College 1-4, 5+
Race (If Hispanic Origin, Specify Cuban, Mexican, etc.)
Father’s Full Name:
Mother’s Full Maiden Name:
* You may call us with this information or send this form via postal mail if you prefer.
In Event of an Emergency Please Notify the Following at Once to Arrange Further Details:
Name:
Relationship:
Address:
City, State, Zip:
Phone:
Are you a U. S. Veteran?	Yes No (If "Yes" please complete the following: )
Branch of Service:
Date Enlisted:
Name of War:
Date Discharged:
Service Number:
Location of Discharge Papers:
FUNERAL SERVICE DETAILS
Church Preference:
Funeral to be held at:	Brust Funeral Home Church
Cemetery (Name and location):
Grave
Section
Lot
Block
Lot is owned in the name of:
Location of Cemetery Deed:
If Interment is to be elsewhere, please complete:
Ship to:
Cemetery Phone:
Receiving Funeral Home: (if needed)
Address:
City, State, Zip:
Phone:
Use an Obituary listing survivors:	Yes No
Preference of Songs to be Sung or Played
Organizations and/or Activities for which I would like to be remembered:
Other Specific Directions / Preferences:
RELATIVES AND FRIENDS TO BE NOTIFIED (Living Parents, Brothers and Sisters, Children, Grandchildren, etc.) Please list the Name, Relationship, Address and Phone# of each person.

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