Pre-Need
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Planning ahead can spare your loved ones from the emotional and financial burdens of making arrangements at the time of loss. Pre-planning can guarantee the exact funeral products and services and save your estate a substantial amount of money. By making decisions in advance, which are so difficult later, you bring priceless peace of mind to yourself and your loved ones.

Think carefully about what will be best for you and your family. Fully discuss why you desire certain arrangements and accompanying merchandise. By arranging today, you are assured peace of mind for you and your loved ones before the time of need. Would you like to leave your wishes on file with us? Would you like more detailed information? You can receive both, free of charge. Please complete the following "PreNeed Online Form."

Your Full Name:


Your Email Address:
Your Maiden Name:


Street/Mailing Address:
City:
State:
Date of Birth:
Place of Birth:
Social Security Number:
Spouses Name:

Spouse Survived?
Yes     No

Marital Status:
Date of Marriage:
Place of Marriage:
Names of Previous Spouses:

Names of Parents:
Address of Parents (if still living):
Names of Children:
Addresses and Phone numbers of Children:
Names of Brothers and Sisters:
Addresses and Phone numbers of Brothers and Sisters:
Names of other friends and relatives who should be notified:
Addresses and Phone numbers of other friends and relatives:
Occupation:
Names of present and previous employers:
Addresses and Phone numbers of present and previous employers:


  
If you are a veteran
Date of enlistment:
Place of enlistment:
Date of discharge:
Place of discharge:
Rank:
Service Numbers:
Organization or outfit:
Commendations received:
Location of discharge papers:
Flag desired to drape casket:


Religious affiliation:

Professional and fraternal organization memberships:

Education (list schools attended and dates of any degrees or honors received):

Names of newspapers for obituary:

Organ Donation (list of authorized card and anyone who should be notified):

Funeral director or funeral home you prefer:

Clergyperson or anyone else you would like to officiate:

Funeral Service Location:

Visitation instructions:
Music, hymns or readings you would prefer during your service:

Memorial Donations you would like in your memory:

Names and Addresses and Phone Numbers of casket bearers:
Cemetery Name:

Address and location of cemetery property (include lot and grave number):

Casket and/or vault preference:

If you wish to be cremated, include disposition preference:

Location of will:

The name of the executor of your estate:

Address and phone number of the executor of your estate:

Location of safety deposit box and key:

Attorney's name:

Attorney's address and phone number:

Location of checking accounts, checkbooks, savings accounts and passbooks:

Credit cards and charge accounts to be canceled. (For security purposes do not list Credit Card Numbers here, just the names of cards.)

Insurance company name and policy numbers:

Location of insurance policies:

Any additional instructions:


 

 

 


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Roth Chapel, 7450 Saltsburg Road, Pittsburg, PA 15235, 412-793-3000, FAX 412-798-9897