Cape Cod Cremation Service

This form is provided as a service to allow the individual to record their funeral preferences. If you are not comfortable sending this information in an e-mail message, please feel free to contact Cape Cod Cremation Service directly or print this page out and place it in a safe location.

Personal Information
Name (First MI Last):

Date of Birth: Place Of Birth:

Address: City:

County: State: Zip:

Years in County: State of Birth:

Phone: E-mail:

Social Security Number:

Spouse's Name: Spouse's Maiden Name:

Spouse's Middle Name:

Place of Marriage: Date of Marriage:

Father's Name: Birth State:

Father's Middle Name: Father's Last Name:

Mother's Name: Birth State:

Mother's Middle Name: Mother's Maiden Name:

Work/Education History
Education Level: Years Completed

Occupation:

Business:

Company: Number Of Years:

Military Service
Service Branch: Serial Number:

Date Enlisted: Rank At Discharge:

Date Discharged: Discharge On File At:

Name Of Wars:

Funeral Preferences
I Prefer My Funeral Service To Be

Place Of Service:

Conclude Service At:

Religious Denomination:

Place Of Worship:

Name:

I Prefer

Type Of Clothing:

Vehicle For Family

Memorialization Instructions
Musical Selections To Be Played

Will Supply CD/Tape

Musical Selections To Be Sung

Favorite Bible Passages:

Favorite Literature Or Poems:

Favorite Flower(s):

Favorite flower color:

Final Disposition
Preference for final disposition is:

Mausoleum entombment

Cremation with

Preference of cemetery or mausoleum is:

Address:

A is owned at the above location

Special Instructions

Obituary Information

Survivor Name Relationship City State

Person To Finalize Arrangements At Time Of Death
Name:

Relationship:

Address:

City: State: Zip:

Phone: E-mail:

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E-mail us: manic@keystonegroup.com