Record of Funeral

							                           Record Of Funeral*** Smith Funeral Home*** Worksheet ****2009****
Name of Deceased          First                          Middle     (Maiden)        Last            Burial Place



Residence       City                                     State                      Zip
                                                                                                    Newspapers to Notify
Decedent's Education                                     Social Security Number



Kind Of Business or Industry                             Usual Occupation



Birthplace   County & State              Date of Birth              Date of Death             Age   Visitation For Family           Day    Time


Location of Death                                                                                   Visitation For Public           Day    Time


                                                                                                    Funeral Services        Day     Time   Place


Father's Name             First                          Middle                     Last            Clergyman


Mother's Name             First          Middle          Maiden                     Last            Flowers


Branch of Service         ( Army, Air Force, Navy, Marine)                                          Memberships:




Active- Inactive- Enlisted- Discharged


Physician's Name & Address                                                                          Pallbearers:                           Music:



Informant's Name                         Relationship                               Phone Number



Mailing Address
                                                                                                    Number of Death Certificates:
Surviving Spouse          Married        Divorced        Widowed    Maiden (if applicable)
                          Record Of Funeral*** Smith Funeral Home*** Worksheet ****2009****
Type of Casket:                                 Type of Vault:                Jewelry:
Picture for Newspaper & Memorial Folder                                       Clothing:
Pictures for memorial tribute




Survivors:




Preceded In Death:




Checklist:
Casket
Vault ordered
Preacher Notified
Gravedigger Notified                            Social Security:                              AmVets Notified:
Hairdesser Notified                             Death Certificates Ordered:                   DD214:
Obits Sent To:                                  Provisional                                   Flag:
Banner                                          Insurance:                                    VA Marker:
Daily News                                      Death Cert Mailed to Dr.                      VA Benefits:
Courier Journal                                 Monument
Answering Service                               Monument Proof
WLBQ                                            Laminated Obits:
WRUS                                            Statement
WKCT                                            Thank You Letter
WGGC                                            Death Date Sent:
Owensboro Messenger