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Egelhof, Siegert and Casper Funeral Homes

Prearrangement Worksheet

Instructions - Use your internet browser print command,

complete by hand and return to us.

Would you like to utilize our Westview or Colonial Location? W or C

First Name_____________________ Middle__________________ Last______________________________

Birth Date______________________ Place of Birth______________________________________________

Current Address _________________________City____________________ State________ ZIP________

Former Address_________________________ City____________________ State________ ZIP________

Current Phone Number___________________ Occupation_______________________________________

Marital Status_______________ Spouse _________________________________Maiden______________

Marriage Date _______________________ Location of Marriage __________________________________

Date of Death of Deceased Spouse______________________ Final Resting Place___________________

Father's Name___________________________ Mother (include Maiden)___________________________

Your Highest Education Level in Years_________________ Veteran Y N Branch________________

Rank___________________________ Date of Entry_________________ Date of Exit_________________

Specify Conflict__________________________ Receiving a Government Pension? Y N

Children and Spouses Names City of Residence State

______________________________________________ __________________________ ___________

Number of Grandchildren______________ Number of Great-Grandchildren________________

Type of Funeral Service you are interested in (Circle)

Traditional Funeral Direct Burial Traditional Cremation Direct Cremation Memorial Service

Questions You Might Have__________________________________________________________________

________________________________________________________________________________________