GARY KELLEY’S ADD’VANTAGE FUNERAL AND CREMATION SERVICE Oklahoma Death Certificate Information NAME by oqc70458

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									                                         GARY KELLEY’S
   ADD’VANTAGE FUNERAL AND CREMATION SERVICE
                                (Oklahoma Death Certificate Information)

NAME ______________________________________________________________ SEX                                   □ M□F
         First          Middle        Last       Maiden Name

STREET ADDRESS _________________________________ PHONE (______) ___________________

CITY ____________________ COUNTY ________________ STATE __________ ZIP _____________

SOCIAL SECURITY NUMBER (Optional) ___________________________

DATE OF BIRTH ___________________ PLACE OF BIRTH _________________________________

NAME OF LIVING SPOUSE (If female full maiden name) _____________________________________

FATHER’S NAME ______________________ MOTHER’S FULL MAIDEN NAME _______________

RACE _____________ OF HISPANIC ORIGIN                 □ YES □ NO IF YES, SPECIFY _____________
ARE YOU A VETERAN ?        □ YES □ NO            BRANCH________ SERIAL NUMBER _______________

OCCUPATION (Before retirement) ___________________ BUSINESS OR INDUSTRY _______________

MARITAL STATUS     □M □D □W □NEVER                        HIGHEST LEVEL OF EDUCATION___________

EMERGENCY CONTACT _____________________________ RELATIONSHIP _________________

ADDRESS __________________________________________ PHONE (______) _________________

MY WISHES WOULD BE FOR □ GROUND BURIAL □ CREMATION

IF GROUND BURIAL, NAME OF CEMETERY ____________________________________________

 □   CHECK THIS BOX IF YOU WOULD LIKE TO “SECURE” THE COST AT TODAY’S PRICE.


            Upon receipt of this completed form an “Emergency Notification” card will be mailed to you.
               Your confidential information will be kept in our secure files until the time of death.


            ADD’VANTAGE FUNERAL AND CREMATION SERVICE

                            9761 EAST 31ST STREET, TULSA, OK 74146

                              Phone (918) 624-2828 ~ Fax (918) 624-2830
30

								
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