Why You Need a Funeral Plan Your Name Date of Birth Your Address Home Phone Mobile Phone Email Social Security Number Who will be your agent responsible to make sure your funeral wishes are followed?Their Name Their Address Home Phone Mobile Phone Their Email Do you need an agent for Body Disposition form? Yes No Are you a Veteran? Yes No Part OneHow do you want your body to be taken care of (check one)? Conventional cemetery burial Green cemetery burial Cremation Whole body donation to science Body organ donation through C.O.R.E Burial At Sea Other If Conventional or Green burial, Please enter Cemetery Name If Body donation to science, Please enter Organization Name If Other, Please Describe Part TwoFuneral Home Name Funeral Home Address OR My family can choose the funeral home when I die, but I don’t want them to spend more than $__________ in funeral home charges. Amount From Above Funeral home services I want (check all that you would like): Embalming Viewing Visitation Burial container: (see below) Memorial service at the funeral home (Note: services elsewhere are covered in Part 3 below.) Newspaper obituary Special burial clothing. Other. If Burial Container (Select all that apply) Coffin Shroud Do not spend more than $ ____________ on my burial container. Amount Limit for Burial Container If Special Burial Clothing, Please Describe If Other, Please Describe Part ThreeService. (Check all that you would like): Religious service Non-religious service Graveside service Clergy person or officiant: Eulogy or sermon Songs: Readings: Other: If Religious or Non-Religious Service, Where will it be at If Clergy or Officiant, Describe Who If Songs, Please list songs you want played If Readings, Please list what you want read If Other, Please Describe Part FourPayment. (Check all that apply): Life Insurance: Funeral trust: Other If Life Insurance, What is Company Name If Life insurance, What is Your Policy Number If Funeral Trust, Bank Name If Funeral Trust, Account Number If Other, Please Describe