BURRIER-QUEEN FUNERAL DIRECTORS, P.A.

Please complete the form below. Click [MAIL] when done. If you would like the print version of this form click here.

Arrangements for:

Last Place of Residence:

City:

County:

State:

Zip Code:

Birth Place:

Date of Birth:

Age:

Sex:
(Male or Female)

Race:

Education:

U.S. Citizen:
(Yes or No)

Hispanic:
(Yes or No)

Usual Occupation:

Industry or Business:

Spouses Name:

Fathers Name:

Mothers Maiden Name:

Social Security Number:

Veteran:
(Yes or No, if NO, do not complete the next eight questions)

Served When:

Entered Service Date:

Discharged Service Date:

Rank:

Branch:

Flag Ordered:
(Yes or No)

Flag Style:
(Folded or Draped)

VA Grave Marker:
(Yes or No)

Physician:

Address:

Phone Number:

FAMILY TO CONTACT

Informant:

Address:

Phone Number:

Name:

Address:

Phone Number:

Name:

Address:

Phone Number:

Do you want to pre-pay the funeral with an Insurance Policy or Trust Account?
(Yes or No)

Home - Services - Staff - Directions - Contact Us - Obituaries
E-Mail: Burrier-Queen Funeral Directors, P.A.