Funeral Preparation Form: *Please print out the following pages and fax, mail or drop off at Schrader Funeral Home*

NAME________________________________________________________________ SEX_____ DATE OF BIRTH ___/___/___ PLACE OF BIRTH______________________________________ SPOUSE (MAIDEN)___________________________________________ SURVIVING (Y/N)___ DATE OF MARRIAGE______________________________ PLACE_______________________ VETERAN (Y/N)____ HONORS DESIRED (Y/N)____ MARITAL STATUS__________________ PRIMARY EMPLOYMENT RESIDENCE USUAL OCCUPATION___________________________ BUSINESS________________________ EMPLOYER___________________________________ LENGTH_______ RETIRED (Y/N)______ STATE_______________________ COUNTY________________ CITY______________________ ADDRESS____________________________________ CITY LIMITS (Y/N)___ ZIP____________ IN WYO____ COUNTY___ CHEYENNE___________ OTHER_____________________________ ORIGIN_______________________ HISPANIC ORIGIN _____MEXICAN _______CUBAN   _____SPANISH _______PUERTO RICAN RACE (WHITE, BLACK, AMERICAN INDIAN)_______________________________________ CITIZEN U.S.A. (Y/N)___ (SPECIFY)______________________________________________ EDUCATION ELEMENTARY/SECONDARY (0-12)___ COLLEGE (1-4 OR 5+)____ HIGH SCHOOL____________________ COLLEGE___________________________________ DEGREES____________________________________________________________________ PARENTS FATHER__________________________________________________ SURVIVING (Y/N)____ MOTHER (MAIDEN)________________________________________ SURVIVING (Y/N)____ ATTENDING PHYSICIAN NAME_____________________________________ ADDRESS_________________________ CITY_________________________ STATE_______________________ ZIP_______________ PHONE________-________________ MILITARY BRANCH_______________________________ UNIT__________________________________ SERVICE NUMBER______________________ WAR_________________________________ ENLISTED DATE_______/______/______ DISCHARGE DATE ________/________/________ FLAG SURVIVORS ____DRAPE _____FOLD PRESENT TO____________________________________________ SPOUSE_____________________________________________________________________ PARENTS____________________________________________________________________ GRANDPARENTS______________________________________________________________ _____________________________________________________________________________ CHILDREN____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ BROTHERS/SISTERS__________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ____GRANDCHILDREN ____GREAT ____GREAT-GREAT ACTIVITIES CHURCH AFFILIATION__________________________________________________________ CRUCIFIX (Y/N)____ PRESENT TO________________________________________________ ORGANIZATIONS______________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ LIST ANY TO PARTICIPATE IN SERVICE__________________________________________ SPECIAL AWARDS OR HONORS________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ CONTRIBUTIONS______________________________________________________________ PREPARATION HAIR STYLING_________________________________________________________________ USUAL BEAUTICIAN________________________________________ PHONE ___-_________ PICTURE AVAILABLE (Y/N)____ COSMETICS ____LIGHT ____MEDIUM ____HEAVY ___REDS ____PINK ____SUNTAN _____NATURAL ___OTHER_________________________ FUNERAL ____SCHRADER CHAPEL ____CHURCH ____OTHER________________________________ OFFICIATING__________________________________ EVENING SERVICE ____ROSARY AND PRAYER SERVICE ____TRISAIGION SERVICE (GREEK) ____SCHRADER CHAPEL ____CHURCH ____OTHER________________________________ OFFICIATING__________________________________ DISPOSITION   ___BURIAL ___CREMATION ___REMOVAL FROM STATE   __DONATION ___OTHER (SPECIFY)_____________________________   PLACE OF DISPOSITION____________________________________________   NAME OF CEMETERY, CREMATORY, ETC. BURIAL LOCATION___________________________________________________________________ CITY________________________ STATE________________________ ZIP______________ SECTION___ ROW____ LOT____ SPACE____ GARDEN_____________________________ MUSIC ORGANIST__________________ VOCALIST_______________ VOCALIST_______________ SONG SELECTIONS___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ EULOGIST________________________________ READER___________________________ SPEAKER________________________________ SPEAKER__________________________ REMARKS ___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________