Shiner Hager Gohlke Funeral Home

Shriner - Hager - Gohlke Funeral Home

PLEASE NOTE: Complete only those items you wish to pre-arrange. Keep these instructions in an accessible

place (not your bank safe deposit box). If you wish, Shriner-Hager-Gohlke Funeral home will keep these

instructions in our confidential files. Tell whoever will be responsible for your personal affairs where this record is

kept. Update this record as time passes so this information is current, as it is used for official documents.

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To print out these forms on a computer, go to "file", "print", check "all", and click on "print".

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VITAL STATISTICAL & BIOGRAPHICAL INFORMATION

Full Name_________________________________________________________________

Address___________________________________________________________________

Birthplace ______________________________Birthdate___________________________

Came to U.S.A.______________________Settled Where___________________________

Schooling__________________________________________________________________

Length of Residence Here______________________Coming From__________________

Lived Previously ___________________________________________________________

Usual Occupation______________________ Employer_______________Retired_______

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Maiden Name______________________________________________________________

Father's Name______________________________________________________________

Mother's Maiden Name ______________________________________________________

Date Married ______________Where___________________To Whom_______________

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Social Security #___________________ If Veteran, War__________Dates____________

Church preference or Member of______________________________________________

Clergy preference__________________________________________________________

Affiliations (Clubs, Organizations, Lodges, Public Office___________________________

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Hobbies, Sports, Favorite Activities, Noted For:__________________________________

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FUNERAL INSTRUCTIONS

Place of Services________________________________________Visitation_____________

Please Specify: Burial______ Entombment_______ Cremation______

Cemetery___________________________________________________________________

Addition_________ Section_________ Block_________ Lot_________ Grave__________

Type of Casket Desired_______________________________________________________

Burial Vault/Urn Desired______________________________________________________

PERSONAL REQUESTS: Memorial Fund For____________________________________

Lodge Services_______________________________________________________________

Military rites________________________________________________________________

Songs______________________________________________________________________

Soloist/Duet_________________________________________________________________

Organist ____________________________________________________________________

SPECIAL INSTRUCTIONS

Clothing_____________________________________________________________________

Hair Dresser ______________________________________Attorney___________________

Newspapers _________________________________________Picture _________________

Other______________________________________________________________________

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LIVING RELATIVES

(Husband/Wife, Children, Parents, Brothers, Sisters)

Relationship Name City & State

___________________________________________________________________________________

Number of Grandchildren _________

Number of Great Grandchildren _________

Number of Great-Great-Grandchildren _________

DECEASED RELATIVES

(Husband/Wife, Children, Parents, Brothers, Sisters)

Relationship Name City & State

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BEARERS

Name City & State Tel. Number

___________________________________________________________________________________

Alternates:

___________________________________________________________________________________

This information is for guidance at the time of my death. It is intended to assist those handling

my personal affairs. I have expressed my preferences on certain subjects which, unless changed

by unforseen circumstances, I hereby desire and request.

Signature __________________________________________________________________________

Full Name _____________________________________________________________Age__________

Address ____________________________________________________________________________

Day/Date of Death____________________________Where ________________________________

Date of Birth ________________________________Where __________________________________

Name of Parents ____________________________________________________________________

Schooling __________________________________________________________________________

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Married Whom _____________________________________________________________________

Married When and Where ____________________________________________________________

Occupation: Where lived or worked ____________________________________________________

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Member of Church, Lodge, Organization; held public office? ______________________________

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Military Record _____________________________________________________________________

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Names & locations of survivors (husband or wife)________________________________________

(Parents) ___________________________________________________________________________

(Sons)______________________________________________________________________________

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(Daughters)_________________________________________________________________________

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(Brothers)__________________________________________________________________________

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(Sisters)____________________________________________________________________________

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Number of Grandchildren _______________ Number of Great-grandchildren _________________

Predeceased by ______________________________________________________________________

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Funeral Time, day/date & place ________________________________________________________

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Clergy/Officiant _____________________________________________________________________

Cemetery & Location ________________________________________________________________

VISITATION time, day/date & place ___________________________________________________

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Memorial fund______________________________________________________________________

Lodge Services, Rosary _______________________________________________________________

1455 Mansion Drive / P.O. Box 86 / Monroe, Wisconsin 53566 / Tel: 608-325-4306 / FAX 608-325-2185