The Young Funeral Home, Inc.
317
East Orange Street
Lancaster,
Pennsylvania 17602
(717)
299 7371
Vital
Statistics Guide
NAME_________________________________________________________________________
CITY,
TOWNSHIP_______________________________________________________________
COUNTY, STATE,
ZIP____________________________________________________________
TELEPHONE___________________________
SEX__________
COLOR__________ MARITAL STATUS__________
CITIZEN__________
BIRTHPLACE_________________________________________________
DATE OF
BIRTH_______________________________________________
FATHER'S
NAME______________________________________________
MOTHER'S MAIDEN
NAME______________________________________
OCCUPATION_________________________________________________
EMPLOYER___________________________________________________
YEAR
RETIRED__________ YEARS WORKED___________
SOCIAL SECURITY
NUMBER____________________________________
SPOUSE
OF__________________________________ (if wife give maiden)
IF VETERAN,
NAME WAR & BRANCH OF SERVICE
_____________________________________________________________
RANK____________________
SERVICE #__________________________
EDUCATION
(highest grade completed)________________
LENGTH OF TIME
LIVING HERE________________
COMING
FROM________________________________________________
RELIGIOUS
AFFILIATION ________________________________________
LIST CLUBS,
NOTEWORTHY ACHIEVEMENTS, ETC.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
SURVIVING
RELATIVES (parents, spouse, children, bro. & sis.)
City & State of residence
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
GRANDCHILDREN
__________ GREAT GRANDCHILDREN___________
SERVICE DETAILS
PLACE OF
SERVICE____________________________________________________________
CLERGY______________________________________________________________________
MUSIC
REQUEST______________________________________________________________
VISITATION
HOURS____________________________________________________________
IN LIEU OF
FLOWERS__________________________________________________________
MY PREFERENCE
FOR CLOTHING, JEWELRY, ETC.________________________________
___________________________________________________________________________
OTHER
INSTRUCTIONS_________________________________________________________
FINAL DISPOSITION
_____BURIAL
_____ENTOMBMENT _____CREMATION
_____OTHER
CEMETERY
NAME_____________________________________________________________
CITY______________ COUNTY_________________ STATE_______
GRAVE SECTION_______________ LOT________________
OTHER
INSTRUCTIONS_________________________________________________________
HAVE YOU MADE A
WILL_________________
NAME OF
EXECUTOR__________________________________________________________
ADDRESS &
TELEPHONE____________________________________________________
IN THE EVENT OF
MY DEATH, PLEASE NOTIFY:
(RELATIONSHIP,NAME,ADDRESS,TELEPHONE)
_____________________________________________________________________________
_____________________________________________________________________________
Last updated 09/02/2005