Get Started with Our Pre-Planning Questionnaire

To begin the Pre-Planning process, we have formulated the following online questionnaire to help gather much of the information needed to begin developing an effective plan, ensuring your end of live desires are met.

While we understand the following questionnaire is quite expansive, it is our hope you should strive to complete and include as much information as possible. Once submitted, we will review your information and contact you accordingly to continue formulating your plan.

For assistance in completing this online planning process, please contact us by calling (815) 699-7711.

Basic Contact Information

* indicates required fields

Your First Name:*
Your Middle Name:
Your Last Name:*
Your Nickname:
Your Phone:*
Your E-mail:*
Current Street Address:
City, State & Zip Code:
County:

Personal Information

Birth Date:*
Birth Place:
Marital Status:

Spouse's Name:
Spouse's Maiden Name:
Marriage Date:
Marriage Place:
Father's Name:
Mother's Name:
Mother's Maiden Name:
Person in Charge:
Their Address:
Their Phone:

Work/Education History

Education (0-12)
College 1-5+
Occupation
Business
Company

Military Record

Branch of Service

Enlistment Date
Discharge Date
Rank At Discharge
Discharge On File At
Copy of Discharge Papers

Name Of Wars

Funeral Service Request

Place Of Service

Funeral Home
Funeral Home Address
Funeral Home Phone
Location of Visitation
Religious Denomination
Place Of Worship

Newspaper Information (Please list family members)

Children
Brothers/Sisters
Grandchildren
Other significant relatives

Special Instructions

Lodges and Organizations
Jewelry
Glasses
Lodge / Union
Clothing Preference

Disposition Request

I Prefer

Cemetery
Cemetery Address
Cemetery Phone
Cemetery Section
Last will & testament exists

Location

Other Instructions

Memorials/Donations To Charity

Please select all that apply:

Send information about pre-arrangement

Contact me to set an appointment

Please keep my information on file