Procedures
MY PERSONAL WISHES FOR PROCEDURES AT THE TIME OF MY DEATH
(extra copies are available at the church office)
NAME: _________________________________________ Date: ________________
I wish to outline my preferences regarding procedures to be followed at the time of my death. I understand that this form is not legally binding, and that the ultimate decisions are to be made by my next of kin. I hope that my wishes will be taken seriously.
(Please leave blank those items that do not apply.)
1. Next of kin or guardian to be consulted at my death:
Name: _______________________________________ Phone: _____________
2. Clergyperson:
I request that the pastor of ______________________ Church be contacted immediately in order that he/she may offer assistance to my family.
3. Funeral Director:
I request that the _______________________________ Funeral Home of (city) ________________________________ be asked to take care of the requested arrangements as itemized therein.
4. Medical Research and Humanitarian Purposes:
a. ( ) I have no objection to a post-mortem examination (autopsy) if there is reason for one to be made.
b. ( ) If possible, I would like the following organs to be donated for another person: __________________________________________________________
5. Disposition of the body: I request that my body be:
( ) buried in ________________________ Cemetery, located at _____________
Family burial plot: Block: _________ Section: __________ Lot: __________
Lot owner: ________________________ Location of deed: ______________
Casket price range: ( ) Low ( ) Medium ( ) High
( ) placed in a crypt in (mausoleum): ___________________________________
( ) cremated, and my ashes be _______________________________________
( ) donated to ___________________ Medical School for anatomical science
studies.
( ) other: ________________________________________________________
6. Religious Service: I request there be:
( ) a memorial service (without the body) at
( ) ____________________ Church; ( ) Home, ( ) Funeral Home.
( ) a funeral service (with the body) at
( ) ____________________ Church; ( ) Home, ( ) Funeral Home.
( ) only a graveside service.
7. Lodge or Military Ceremony:
Please notify the following lodge and/or military organizations to arrange for
special services: ___________________________________________________
________________________________________________________________
( ) I would like a flag for the casket (veterans only). Honorable discharge from
U.S. Military Service is located ____________________________________
(Suggestion: Have a photocopy made and keep at home; original in safe
deposit box.)
8. Memorial Donation or Flowers: I request that there be:
( ) flowers ( ) no flowers
I request that there be donations in lieu of flowers to:
( ) Memorial Fund of ____________________________ Church.
( ) Other: ________________________________________________________
9. I have ( ), have not ( ) made out a will. A copy of the will is located _____________.
10. I have ( ), have not ( ) made out a "living will." A copy of this document is located
________________________________________________________________
11. ( ) I would like to discuss with the pastor leaving a gift for Hope Presbyterian
Church from my estate.
12. Other choices or wishes, if applicable:
Favorite hymns or scripture selections I hope can be used in religious service:
Hymns: __________________________________________________________
Scripture: ________________________________________________________
Pallbearers: ______________________________________________________
________________________________________________________________
Other wishes: _____________________________________________________
13. Information needed for death certificate and/or newspaper notices:
Full name: _______________________________________________________
Address: _________________________________________________________
Social Security Number: ____________________________________________
Birth date: _________________ Birthplace: _____________________________
Father’s full name: ____________________His birthplace: _________________
Mother’s full name: ____________________Her birthplace: ________________
Last occupation: ________________________________ Since _____________
Last employer: __________________________________Since _____________
Veteran (war or dates) ______________________________________________
Married _____ Widowed _____ Divorced ____ Never married _____
Name of surviving spouse: ___________________________________________
Present or past occupation of spouse: __________________________________
Surviving parents: _________________________________________________
No. List names
_____ children: ___________________________________________________
_____ brothers: ___________________________________________________
_____ sisters: _____________________________________________________
_____ grandchildren _____ great-grandchildren _______ nieces and nephews
Memberships: Church ______________________________________________
Lodges _____________________________________________
Other organizations ____________________________________
___________________________________________________
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Copies of this expression of my wishes are filed with:
_________________________________________ Church
___________________________________________________________ Relative(s)
_________________________________________ Funeral home (if desired)
Signature: _______________________________________ Date: _________________
Please fill out one copy for each adult member of the family. It is requested that the church office be supplied with a copy of the form.