By planning ahead now, you will be ensuring that those you love will never have to go through this alone.

Vital Statistics Record
First Name
Middle Name
Last Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Country
Home Phone
E-mail
Social Security #
Birthplace
Birth Date
Father's Full Name
Mother's Name Including Maiden Name
Marital Status	Married Divorced Single Widowed
Spouse
Marriage Date
Marriage Place
If Deceased when? (if applicable)
Spouse
Marriage Date
Marriage Place
If Deceased when? (if applicable)
Doctor's Name
Doctor's Address
Personal History
Occupation
Employer
Position Held
How Long
Retired	Yes No
Retired When?
Resident Cities  & Years:
Education
Military Experience
War
Rate or Rank
Entry Date & Place
Discharge Date  & Place
Service Number
Lodges Memberships Church & Public Office Held
General Biography for Media & Funeral Service Folders
We will notify the local newspaper The Peoria Journal Star and Pekin Daily Times. Is there any other newspapers you would like us to notify?
Other Newspapers:
Picture enclosed	Yes No
Immediate Family Information
Name & Relationship, City & State
Preceded By
Local Emergency Contacts to be Notified at Need
Name
Address
Phone
Name
Address
Phone
Important Legal Information for Family Use
Will
Attorney
Safe Deposit Box at
Executor of Estate
Address
Any Additional Pertinent Information
Funeral Service Instructions and Information
Place of Service	Funeral Home/Chapel Church Graveside Only
Type of Disposition	Cremation Burial Mausoleum Entombment
Cemetery
Location
Section
Lot
Space
Marker Installed
Remarks
Clergy
Church
Organist
Vocalist
Music Selections
Favorite Bible Passages &  Poetry & Quotations & Verses Etc.
Flower Requests
Clothing	New Present
Color
Jewelry
Decisions of Clothing & Jewelry to be made by?
Participating Organizations (Fraternal/Military Rites)
Pallbearer
City
Pallbearer
City
Pallbearer
City
Pallbearer
City
Pallbearer
City
Pallbearer
City
Alternates/Honorary
Special Instructions	I have given the preceding information to be filed confidentially with Preston-Hanley Funeral Home in order to avoid placing all responsibility on family and loved ones at the time of my death.