Pre-arrangement Application

  1. Please complete information

    First name

    Middle Int.

    		  

    Last Name

    		  
    Sex Male Female

    Date of birth

    		   Age

    SSN

    		   Telephone

    Address

    		  

    Place of Birth

    		  

    Employer

    		  

    Education

    		  

    Branch of Service

    		  

    Organizations

    		  
    Father's Name
    Mother's Name
  2. Final Details
    Church/Location
    Cemetery/Location
    Clergy  
    Executor
    Street address
    City/State/Zip
    Telephone
    Music
    Type of Burial
    Special Requests
  3. Merchandise Selected and Type of Service
    Casket
    Outer Burial Container
    Clothing
    Headstone/Monument
    Beautician/Barber
    Florist
  4. List all Survivors/Relationships and City & State, please include active and honorary pallbearers.


Rollins Funeral Home, Copyright, 1999.  All rights reserved.
Last revised: April 03, 2002