Funeral Arrangements Form

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Local Florist

(262) 654-3533

5111-60th Street, Kenosha, WI 53144

(262) 654-3533

5111-60th Street, Kenosha, WI 53144

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Home
About
Obituaries
Our Services
Funeral Planning
- Pre-Planning
- How to Plan a Funeral
Grief & Guidance
- Grief
- Guidance
Funeral Arrangements Form
Make a Payment Online
Local Florist

Funeral Arrangements

VITAL STATISTICS

*First:

Middle:

*Last:

Social Security Number (SSN):

Maiden Name (If Applicable):

Address Line 1:

Address Line 2:

State:

City:

Zip Code:

Sex:

Male

Female

Race/Ethnicity:

Citizen:

United States

Other

Birthplace:

Date of Birth:

Father's First Name:

Last Name:

Mother's First Name:

Maiden Last Name:

Marital Status:

Single

Married

Divorced

Widowed

Spouse's First Name:

Spouse's Last Name:

Surviving Spouse's Maiden Name (If Applicable):

Date & Place of Marriage:

Employment Status:

Retired

Employed

Not Employed

Do not use Retired as an occupation

Usual Occupations:

Type of Business:

Employers / Years:

Highest Education Completed:

Grade School

Middle School

High School

College

University

Other

Schools Attended / Degree(s) Earned:

Veteran:

Yes

No

Branch of Service / Rank / Service Number:

Service Dates:

Survivors

SURVIVORS

Spouse:

Parent(s):

Children:

Grand Children:

Great Grand Children:

Siblings:

Other Survivors:

Preceded in Death by:

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VISITATION / GATHERING

Day:

Hours:

Day:

Hours:

Casket Opened For:

Family & Friends

Family Only

No Viewing

Special Set Up:

SERVICE

SERVICE

Type of Service:

Traditional

Mass

Graveside

Memorial

Date:

Hour:

Place:

Clergy:

Music:

Standard

Special Selection

List Special Selections:

Organist:

Pianist:

Pallbearers:

Honorary Pallbearers:

Committal Service:

Immediately Following

Other

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FINAL DISPOSITION

Internment, Cremation or Entombment:

Date:

Hour:

Cemetery/Crematory:

City/Town:

State:

Zip:

County:

Grave Number:

Lot:

Section:

Block:

Lot Purchased:

Lot Owner:

Outer Container/Vault Provided by:

Marker

Disposition of Cremated Remains:

Free Text

Thank you for taking the time to register your information with us, how can we best reach you to follow up?

*First Name:

*Last Name:

*Phone Number:

*Email Address:

Informant Address

Thank you for contacting us.
We will get back to you as soon as possible.

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Phone: (262) 654-3533

Proko Funeral Home

5111-60th Street

Kenosha, WI 53144

Fax: (262) 654-3539

rachael@prokofuneralhome.com

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VITAL STATISTICS

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