124 West Miller Street, Newark, NY 14513 - 315-331-1175
I am planning for:
myself parent friend spouse
First Name:
Middle:
Last:
Address:
City:
State:
Father's Name:
Mother's Maiden Name:
Date of Birth:
Place of Birth:
Marital Status:
Name of Spouse:
Date Married:
Place Married
If Spouse deceased, year:
Please list schools attended from grade school, trade, college, ect.
Total Number of Years:
Church Affiliation: Service Organizations: Awards, Politics, Ect.:
Please list the names, cities and states of the following:
Spouse: Children: GrandChildren: Parents: Brothers: Sisters: Nieces and Nephews: Other:
In lieu of flowers, Memorial Contributions may be made to:
Special Music: Special Readings: Pallbearers: Other Information or Instructions:
Branch of Service:
War:
Date and place of entry:
Date and place of exit:
Honors / Commendations:
Thank you.
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