By taking a few moments to complete the form below, we will be able to provide you with the exact information you want. We will respond to your request as soon as possible.
CONTACT INFORMATION
FIRST NAME:  
MIDDLE NAME:  
LAST NAME:  
STREET ADDRESS:
CITY:   STATE:   ZIP:  
PHONE NUMBER:
EMAIL ADDRESS: (Required)

BIOGRAPHICAL INFORMATION
Date of Birth:
Place of Birth:
Father's Name:
Mother's Name:
Mother's Maiden Name:
Social Security Number:
Occupation:
Type of Business / Industry:
Employer:
Number of Years Employed:
Year Retired:
Are you a member of a church?YesNo
What is the name of your church?
Please list any groups, clubs or organizations you are a member of:


VETERANS INFORMATION
Veteran:YesNo
If Yes, which branch?
Period of Service:
Service Number:
Date of Entry:
Date of Discharge:
SURVIVING FAMILY MEMBERS


NAME RELATIONSHIP

SERVICE INFORMATION
Do you prefer:BurialCremation
If you prefer earth burial, do you own cemetery property?YesNo
Name of Cemetery:
What type of service do you want?
TRADITIONAL
This service type includes all of our profesional services, one day/evening visitation period for a maximum of three hours, the funeral ceremony in the funeral home or church of your choice and automotive equipment. It does not include limosines for the family and pall bearers.
GRAVESIDE SERVICE WITH VISITATION
This service type includes all of our profesional services, one day/evening visitation period at the funeral home for a maximum of three hours, the funeral ceremony in the cemetery of your choice and automotive equipment. It does not include casket, outer burial container or limosines for the family and pallbearers.
GRAVESIDE SERVICES WITHOUT VISITATION
This service type includes all of our profesional services, the funeral ceremony in the cemetery of your choice and automotive equipment. It does not include casket, outer burial container or limosines for the family and pallbearers.
TRADITIONAL SERVICE FOLLOWED BY CREMATION
This service type includes all of our profesional services, one day/evening visitation period for a maximum of three hours, the funeral ceremony in the funeral home or church of your choice, automotive equipment, crematory fee and a basic urn. It does not include rental casket or limosines for the family and pallbearers.
CREMATION WITH A MEMORIAL SERVICE
This service type includes minimal profesional services and automotive equipment, the memorial ceremony in the funeral home or church of your choice, minimum cremation container, crematory fee and a basic urn.
CREMATION WITH NO SERVICE
This service type includes minimal profesional services and automotive equipment, minimum cremation container, crematory fee and a basic urn.
DIRECT BURIAL WITH NO SERVICE
This service type includes minimal profesional services and automotive equipment. It does not include casket, outer burial container or any cemetery related expenses.
Where would you prefer to have your service?
Who would you like to speak at your service?
What is their name?
Please list any special songs you would like played at your service.

Would you like a limosine to take your family to the place of your service and to the cemetery?YesNo
Do you know who you would want to serve as pallbearers?YesNo
If so, you can list their names here.
Do you want a limosine to take the pallbearers from the place of your service to the cemetery?YesNo

CASKETS
Do you prefer:Metal CasketsWood Caskets

OUTER BURIAL CONTAINERS
Do you want an outer burial container that: is designed to protect the casket from grave elements?YesNo

OTHER QUESTIONS OR CONCERNS
Please feel free to use the space below to ask any other questions you may have and we will do our best to answer them.


At this point, what would you like us to do with the information you have proveded?
Just keep the information on file
Keep the information on file and contact me about prefunding my funeral expenses
Would you like us to answer your requests by:
Phone
E-Mail
Regular Mail
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Copyright Maple Hill Funeral Home, 2006