Address: 1997 Meadowbrook Road, Benton Harbor, Michigan, 49022, US
Telephone: (269) 926-9440

Contact Person
Name*
First Last
Middle Name
Address*
Street Address City State ZIP Code
Email
Phone*
Cell Phone
Work Phone
Social Security Number
Social Security Number will need to be provided at time of arrangements
Relationship to Deceased*
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Deceased Person Information
Name*
First Last
Middle Name
Sex*
Date of Birth*
Date Format: MM slash DD slash YYYY
Birthplace: City, State, Country*
Marital Status*
Name of Spouse (maiden name, if wife)
In Armed Forces*
Social Security Number*
Usual Occupation*
Kind of Business/Industry*
Education (highest completed) Elementary & Primary (0-12)*
Higher Education*
Address*
Street Address City State ZIP Code
Father
Father's Name*
First Last
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Middle Name
Step-Father Name
Mother
Mother's Name*
First Last
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Middle Name
Maiden (last) Name*
Legal forms require this information. If you do not have this information, 'Unknown' will need to be inserted.
Step Mother Name
Cemetery Information
Burial/Cremation/Anatomical Study*
Cemetery Name
Location City/Location State of Cemetery
Church Information
Church Name
Denomination
Church Address
Street Address City State ZIP Code
Church Phone
Minister's Name
First Last
Minister's Phone
Family Information
Children (oldest to youngest with spouse info)
First (Spouse) Last
Grandchildren (oldest to youngest with spouse info)
First (Spouse) Last
Great Grandchildren (oldest to youngest with spouse info)
First (Spouse) Last
Siblings (oldest to youngest with spouse info)
If siblings are deceased, please type "deceased" before the respected name.
First (Spouse) Last
Membership in Organizations, Clubs or Societies
Organizations, Clubs, Societies: Name & Contact Information
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People / Groups to Notify about Funeral Services
Name of Person / Group & Email Address
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Name
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Contact Person

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Deceased Person Information

Father

Mother

Cemetery Information

Church Information

Family Information

Children (oldest to youngest with spouse info)

Grandchildren (oldest to youngest with spouse info)

Great Grandchildren (oldest to youngest with spouse info)

Siblings (oldest to youngest with spouse info)

Membership in Organizations, Clubs or Societies

People / Groups to Notify about Funeral Services