Pederson Funeral Home

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Personal Information

First Name:
Middle Name:
Last Name:
Date of Birth:
Birthplace:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Email Address:

Father's Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:

Mother's Maiden Name:
Address - if living:
City:
State/Province:
Zip/Postal Code:

Where were you raised and what schools did you attend?

Highest level of education:

Maiden Name of Spouse:
Date of Marriage:
Place:
If deceased, date of death:

Where have you lived during your adult life?

Name of children & their spouses, and their addresses

Child#1 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#2 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#3 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#4 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#5 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Current Number of Grandchildren:
Current Number of Great Grandchildren:

Names of surviving brothers & sisters and their addresses

Sibling#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Preceded in death by

Occupation. Give the type of work done most of working life, even if retired.

Name of Employer:

If Retired, Date of Retirement:
Total years spent in your occupation:

Church affiliation & activities:

Did you serve in the military? Yes No

If yes, what branch:

List membership in fraternal, civic, or professional organizations:

Special events in my life not listed previously:

FUNERAL INSTRUCTIONS

Place of Service:

Minister:

Music Selections:

Organist:

Singer(s):

Singer#1:

Singer#2:

Singer#3:

Singer#4:

Singer#5:

Pallbearers:

Pallbearer#1:

Pallbearer#2:

Pallbearer#3:

Pallbearer#4:

Pallbearer#5:

Pallbearer#6:

Pallbearer#7:

Pallbearer#8:

Favorite Bible Selections:

Special Services (Military or Lodge)

Cemetery Information

Name of Cemetery:
Location City:
Lot is in the name of:
Section:
Lot:
Grave Space:

Casket and Burial Preferences

Casket:
Metal:
Wood:
Exterior Color:
Interior:
Burial Vault:

Authorized Persons to Arrange Final Details

Person#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

My Special Wishes

Clothing, jewelry, etc.