3720 39th Avenue
Kenosha, WI 53144
(262) 658-4101
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Funeral Arrangements Form
Piasecki Funeral Home
2020-06-20T10:27:13-05:00
Funeral Arrangements
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VITAL STATISTICS
Name of person for whom the funeral is being planned for:
*
First
Middle
Last
Maiden Name (If Applicable)
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Sex
Male
Female
Race/Ethnicity
Citizen:
United States
Other
Birthplace
Date of birth
Father's First / Last Name
First
Last
Mother’s First/Maiden/Last Name:
First
Last
Social Security Number
Marital Status
Married
Single
Divorced
Widowed
Surviving Spouse
First
Last
Surviving Spouse's Maiden Name (If Applicable)
Date & Place of Marriage
Employment Status
Retired
Presently Employed
Not Employed
Usual Occupations
Type of Business
Employers / Years
Highest Education Completed
Grade School
Middle School
High School
College
Schools Attended / Degree(s) earned
Veteran
Yes
No
Branch of Service / Rank
Service Dates
Service Number
BIOGRAPHICAL INFORMATION
Length of time living in this area
Moved from
Religion
Church Affiliation:
Member
Attended
Non-Member
Church/Synagogue
City
Clubs, Organizations, etc:
Hobbies and Interests:
SURVIVORS
Spouse
Parent(s)
Children
Grand Children
Great Grand Children
Great-Great Grand Children
Sisters / Brothers
Other Survivors
Preceded in Death by
VISITATION / GATHERING
Day
Hours
Day
Hours
Casket Opened for
Family & Friends
Family Only
No Viewing for Anyone
Room
Special Set Up
Catholic
Other
Rosary
Wake
SERVICE
Type of Service
Traditional
Mass
Graveside
Memorial
Date
Hour
Place
Clergy
Music
Standard
Special Selections
List Special Selections
Organist(s)
Soloist(S)
Pallbearers
Honorary Pallbearers
Committal Service
Immediately Following
Other
Describe Other Committal Service
Flowers
Flowers Accepted
In Lieu of Flowers, Memorials to
List Memorials In Lieu of Flowers
FINAL DISPOSITION
Internment, Entombment or Cremation
Internment
Entombment
Cremation
Date
Hour
Cemetery/Crematory
City / Town
State
Zip
County
Grave Number
Lot
Section
Block
Lot Owner
Lot Purchased
Pre-need
At Need
Outer Container/Fault Provided by
Marker
Disposition of Cremated Remains
ADDITIONAL INFORMATION
Newspaper Notices in
Flowers to Order
Hair Styling
Jewelry
Glasses
Yes
No
Clothing
Other Notes
Thank you for taking the time to register your information with us, how can we best reach you to follow up on the material you provided?
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Phone
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Email
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