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Pre-Planning Form

The following Pre-Planning Form will allow you to gather information needed to begin the Pre-Planning process. Once you have completed the form click on the submit button and a preformatted page will appear, allowing you to print the results and file away for safe keeping. Once you have printed the form, use your browser's back button to return to this page.

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Action: New Form   Update Form

Date:

Personal Information

Name

Sex

Race

Marital Status

Social Security #

Date of Birth

Age

Place of Birth

Address

City

State

Zipcode

 .......

Phone

Email

Spouse's Name

Spouse's Maiden Name

Wedding Anniversary Date

Date of Marriage

Father's Name
Mother's Name

Mother's Maiden Name

Church Membership
Names of Your Children and Town They Live In
Names 0f Your Grandchildren & Great-Grandchildren
Names of Your Brothers & Sisters and Town They Live In
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Work/Education History

Education (0-12)
Name of School

College (1-5+)
Name of College

Occupation

Business

Company Name
Organizations You Belong To
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Military Record

Branch of Service

Serial Number

Date Enlisted

Rank at Discharge

Date Discharged

Discharge On File At

Copy of Discharge Papers:   Yes    No

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Funeral Service Request

Place of Service

If other, please specify

Place of Visitation or Viewing

Private Viewing   Public Viewing

Primary Contact Person & Phone Number for Funeral Arrangements
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Other Instructions/Comments
(Music Request, Flowers, Personal Preferences, Etc)

Memorials/Donations to Charity

Security Code

Please enter the code in the box below:

kOLLeR

 

          

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Copyright © 2002 Koller Funeral Home and Cremation Center, Inc.
2000 W. Market Street - York, Pennsylvania 17404

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