ABOUT US
OBITUARIES
SERVICES
RESOURCES
PLANNING AHEAD
GRIEF SUPPORT

Wyoming: (570) 693-1130

Monroe TWP : (570) 639-5115

ABOUT US
OBITUARIES
SERVICES
RESOURCES
PLANNING AHEAD
GRIEF SUPPORT

PRE-ARRANGEMENTS FORM

Pre-arrangements FORM

Pre-Arrangement Form

ID Number:

Name:

Age:

Date of Death:

Hour:

Arrangement Appointment - Day & Time:

New Field:

At Funeral Home

At Residence (Address):

Informant Interviewed by:

New Field

Relative File

News Article/Picture

Embalming Authorization

Picture

Pre-Arrangement

Free Text

Vital Statistics

Decedent’s Street Address:

City-Township:

County:

State:

Place of Death:

City-Township:

County:

State:

Specify:

In-Patient

DOA

ER

Residence

Certifier of Death Certificate:

Certifier’s Address:

Sex:

M

F

Race-Ethnicity

Citizenship:

Birthplace:

Date of Birth:

Father’s Name:

Mother’s Maiden Name:

Marital Status (M,W,D,S):

Surviving Spouse:

Date & Place of Marriage:

Employment Status:

Usual Occupation

Kind of Business/Industry

Employer:

City:

No. of Years:

Social Security No. :

Highest Education:

Veteran?

Yes

No

Branch of Service:

Rank:

Services Dates:

Service No. :

Date of Entry:

Place of Entry:

Date of Separation:

Place of Separation:

Honors/Commendations:

Free Text

Informant's Information

Informant's Name:

Relationship:

Informant's Street Address:

City-Town:

State:

Zip Code:

Informant's Day Telephone:

Informant's Evening Telephone:

Free Text

Obitaury Information

Resident since:

Moved here from:

Religious affiliation:

Church:

City:

Clubs, Organizations, Other Information:

Free Text

Survivors

Spouse:

Date of Marriage:

If deceased, year:

Parent(s):

Children:

Brothers:

Sisters:

No. of Grandchildren:

No. of Great Grandchildren:

No. of Great-Great-Grandchildren:

Precedents:

Special Notes:

Free Text

Visitation

Day:

Hours:

Place:

Day:

Hours:

Place:

Casket Opened:

For Friends & Family

Family Only

No Viewing for Anyone

Room:

Special Setup

Catholic

Flag

Military

Military time:

Masonic Apron

Masonic Time

New Field:

Rosary

Wake

Time:

Free Text

Funeral Services

New Field:

Traditional Funeral

Mass

Graveside Service

Memorial Service

Day:

Date:

Hour:

Place:

Clergy:

Music Special Selections:

Organist:

Soloist:

Address:

Pickup Time:

Address:

Pickup Time:

When will the casket be closed?:

Jewelry instructions:

Free Text

PALLBEARERS

New Field:

Professional

Selected by Family

Honorary

We Notify

Family Notifies

New Field:

Committal Service

Immediately Following Funeral Service

Other:

If Other:

Flowers:

Accepted

Family to provide

Display Ad

Display to read:

DISPOSITION

Interment

Entombment

Cremation

Cemetery/Crematory:

Day:

Date:

Time:

Address:

City-Town:

County:

State:

Grave No. :

Section:

Block:

Outer Container/Vault Provided By:

Marker:

Disposition of Cremated Remains:

Grave, Lot Drawing:

Newspaper Notices in:

Sun Gazette

Press Ent.

Sullivan Review

Luminary

Other

Flowers to order:

Jewelry:

Glasses:

Clothing:

Hair Styling:

Memorabilia:

Free Text

Billing/Accounting Information

Bill to:

No. of Certified Copies Requested:

Estate’s Attorney:

Free Text

MORTUARY RECORDS

Casket Name:

Casket Number:

Casket Material:

Casket Manufacturer:

Exterior Color:

Interior:

Outer Container Name:

Outer Container Material:

Outer Container Manufacturer:

Outer Container Color:

Urn:

Post-Mortem Examination:

Yes

No

Post-Mortem Examination Done By:

Removal by:

Embalming by:

Funeral Director:

Free Text

Notes

Reason family selected funeral home:

Other Notes:

Free Text

Out-Of-Town Arrangements

Transfer Remains:

To

From

Funeral Home:

Shipping

Trade Shipping Service

Full-Service Funeral Home

Street Address:

City:

State:

Zip Code:

Telephone:

Director:

Price Quoted by/To Director:

Pre-Paid

Prepaid

COD

Ship via:

Our Vehicle

Their Vehicle

Airline

Which Airline:

Depart (Airport)

Day:

Time:

Airline:

Flight #:

Arrive (Airport):

Time:

Outer Shipping Container:

Escort/Passengers:

Special Information:

Free Text

Arrangements

Pre-arrangements:

On File

Not on File

Embalming authorization received:

Family Interviewed

FTC's "Statement" Completed:

Clergy Notified

Pallbearers Notified

Newspaper I

Newspaper II

Other III:

Other IV:

Cemetery/Crematory Notified

Notify Employees: Viewing

Notify Employees: Service

Opening of Grave Arranged

Outer Container Ordered

Clothing Obtained

Register Book

Memorial Folders

Acknowledgement Cards

Prayer Cards

VA Flag Obtained

Military Service

Masonic Service

Flowers Ordered

Musician(s) Notified

Tempor

Yes

No

Casket:

In-Stock

Ordered

Re-Ordered

Free Text

DOCUMENTS/PRE-SERVICE

Death Certificate

Certified Copies

Clergy Record

Vault Warranty

Burial Permit

Heritage

Temporary Marker

Clergy Gratuity

Musician(s) Gratuity

Cemetery Check

Hairdresser Check

Laminates

MV Forms

Free Text

VEHICLES/PRE-SERVICE

Traffic Escort

Family Car(s)

Clergy Car

Funeral Coach-Hearse

Limousine

Flower Vehicle

Other:

Free Text

Post-Service Follow-Up

Certified copies delivered/mailed:

Social Security:

New Field:

Fed.

Co.

VA Marker

Insurance claim

Other claim:

Monument lettering:

Monument Sale:

Yes

No

Follow-up #1

Follow-up #2

Follow-up #3

Follow-up #4

Follow-up #5

Follow-up #6

Free Text

Notes

Free Text

Notes

Note

Note

Note

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Metcalfe Shaver Kopcza Funeral Home INC.

Nulton Kopcza Funeral Home

5749 SR 309 Monroe TWP, PA 18636

© Metcalfe Shaver Kopcza Funeral Home, Inc.. All Rights Reserved.

© Metcalfe Shaver Kopcza Funeral Home, Inc.. All Rights Reserved.

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