Pre Arrangement or Pre Need Form

Name (First Middle Last):

Marital Status: MarriedNever MarriedDivorcedWidowWidower    Date of Birth:

Place of Birth:

SSN#:    Race:

Current Address:

City:    State:    Zip Code:

County:

Telephone:

Email:

Spouse's Name:

Spouse's Maiden Name:

Place of Marriage:

Date of Marriage:

Father's Name/Birthplace:

Mother's Name/Birthplace:

Mother's Maiden Name:

Career or Education History

Education(0-12):     College (1-5+):

Occupation/No. of Years:     Business Type:

Company Name:

Military Service Record

Branch of Service:     Serial Number:

Date Enlisted:     Date Discharged:

Rank at Discharge:  

Copy of Discharge Papers: yes no

Name of Wars:

Contact Information

Next of Kin

Next of Kin Address:

Next of Kin Telephone:

Funeral Service Request

Place of Service: Funeral HomeChurchCemetary

Place of Visitation:

Religious Preference:

Place of Worship:

Lodge/Union:

Disposition Request

I prefer: Earth BurialMausoleumCremation

Cemetery:

Address:

Phone:

Section:

Where is Last Will & Testament on file?:

Other Instructions:

Memorials/Donations to Charity:

Please choose of the options below:

Send information about pre-arrangement

Contact me to set up an appointment

Please keep my information on file

Please click once on the Submit button below to send your information and requests to  Claffey & Rota Funeral Home, Napa Valley.