Recording Your Last Wishes

It is important to list names, addresses, and phone numbers of people to be contacted immediately in the event of death (e.g., clergy, lawyer, employer, immediate family, funeral director). Decisions should be put in writing and left where the document can be easily found by family, a friend, or lawyer--not in a safe deposit box or in a will. It is also important to include the location of any safe deposit box (state number) and safe deposit key.

The following is a form which, when completed, can supply the family and others with information needed after an individual's death. We recommend you print it out and complete it.

IMPORTANT INFORMATION IN THE EVENT OF MY DEATH

My name is____________________________________________________________________
                                 first                    middle/maiden                       last
When I die, please contact________________________________________________________
                                                                   name                                   relationship
My important papers are located at________________________________________________

INFORMATION FOR DEATH CERTIFICATE AND FILING FOR BENEFITS

My street address_______________________________________________________________
City______________________County____________State_______Zip code____________
Citizen of______________________________________________Race___________________
Birthplace___________________________________________Date of Birth______________
Social Security Number__________________________________________________________
Occupation/type of business_____________________________________________________
If veteran: rank_______________branch of service____________serial no.___________
date and place entered service______________________________date discharged______
I have ___never married, ___ married, ___been widowed, ___separated, ___divorced, ___
                           ___remarried.
Spouse's full (maiden) name______________________________________________________
Name of next of kin (other than spouse)_____________________________________________
Relationship_____________________Address____________________________________________
Father's full name and birthplace__________________________________________________
Mother's maiden name and birthplace______________________________________________

PLEASE NOTE: AFTER DEATH I PREFER
To donate these organs__________________________________________________________
That my body be:
_____donated: arrangements made on (date)________________________________________
       with: medical school________________________________________________________

I prefer: ____simple arrangements, ____no embalming, ____no public viewing,
          ____the least expensive burial or cremation container, ____immediate disposition
              _______ a nice funeral
            ____cremated and the ashes       _____ scattered or    _____buried
               in ________________________________________________________________
               or disposed of as follows______________________________________________
         ____buried: at location___________________________________________________
  The following services: ___memorial (after disposition) ____funeral (before disposition)
                                      ____ graveside
   Services to be held at:  ____my church  ____ mortuary ____other__________________
           Memorial gifts to __________________________________; omit flowers________
  I have made prearrangements with (mortuary)__________________________________

Signature________________________________________Date_______________________