Please use this online Service Information Form to send us your information.  Or, if you'd like, you can download the form by clicking here, and bring it with you to our office or fax it to us at:(662) 456-5093.

Name:
First, Middle, Nickname, Maiden, Last

Mailing Address:

City: State: Zip:

Street Address (specify if the same):

City: State: Zip:

Phone (home):    Phone (work):  

Place of Death:

Date of Death:

Sex:

Never Married Married Widowed Divorced

Husband of (Maiden Name):

Wife of:

Birthplace of Deceased:

Date of Birth: Age: Social Security #:

Veteran (War and Unit):

Veteran (Rank):

Completed Education 1-12:

Completed Education 1-5+:

Occupation:

Position Held:

Father's Full Name:

Mother's Maiden Name:

Funeral Service At:

Date: Time:

Cemetery: City:

Minister(s):

Music:
name of musicians

Music:
name of songs

Family Visitation:
(Date and time to be determined at time of Arrangements Conference)

Visitation:
(Date and time to be determined at time of Arrangements Conference)

Memorials:
Complete with mailing addresses if possible

Name of Florist to Supply Family Flowers:

Would You Like a Hairdresser? If so, Please Give Name:  
Phone:

Active Pallbearers (6-8) Please list full names and phone #s if you would like for us to call for you. Names can be supplied later during the day.

Honorary Pallbearers (If Desired) Please list full names and phone #s if you would like for us to call for you. Names can be supplied later during the day.

Background Information (Church Membership, Clubs, Organizations, Civic or Charitable Work, etc.)

Surviving Relatives and Addresses (the way you want it to appear in the newpapers):

Father's Name:

Address:

City: State: Zip:

Mother's Name:

Address:

City: State: Zip:

Husband's Name:

Address:

City: State: Zip:

Wife's Name:

Address:

City: State: Zip:

Daughters:
name and address

name and address

name and address

name and address

name and address

Sons:
name and address

name and address

name and address

name and address

name and address

Sisters:
name and address

name and address

name and address

name and address

name and address

Brothers:
name and address

name and address

name and address

name and address

name and address

Number of Grandchildren:

Number of Great Grandchildren:

Number of Great Great Grandchildren:

Surviving Grandparents:
name and address

name and address

name and address

name and address

name and address

If you have any questions about the funeral service or related items, please make notes so we can discuss them at the Arrangements Conference.

If possible, please bring to the Arrangements Conference clothes to dress your loved one for burial: or, if you prefer, we will show you what we have available for purchase. Clothes should include the usual undergarments, outer garments, and hose/socks. We suggest long-sleeved garments for both men and women. We also suggest a full slip for women. Shoes and belts are not required, but we will use them if they are furnished.

Please click "Submit" when you are ready to send us your information.  You will then be automatically redirected to our home page.  We will respond shortly.  Thank you.