Eol Planning Worksheet March2008

PERSONAL PLANNING SHEET FOR

(Name)

General Information Street Address A

Date of Birth

City, ST Zip

Emergency Contact(s)

Phone B

Veteran

Branch and Dates of Service (If checked, Contact Regional Veterans Affairs)

Pre-arrangements

C

Advance Directives

Have been made

Living will / medical power-of-attorney

Need to be made

Need Developed

Can be made when needed according to this plan

In effect

Funeral Home

Designated agent(s)

Phone

Location of Document

Contact

Desire Home / Hospice Care

Preferences and Arrangements Obituary Notes: D

Services

Select any and all options that denote your preferences None

Religious Affiliation, if any

Private

Public

Graveside Only

Eucharist / Last Rites

Rosary

Visitation

Viewing

Funeral

Celebration of Life

Mass of Christian Burial

Church

Synagogue

LOCATION:

Other Location

Preferred Officiant

(Name & Title)

Name of Location Street Address

E

City, ST Zip Phone

(

)

—

Clothing to be dressed in: Other specific details: Music None

Songs Instrumental Vocalist Congregational Singing

Print Name

Signature

Date

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PERSONAL PLANNING SHEET FOR Services

(Name)

(Cont'd)

Scripture Verses

Inspirational poems, quotes or thoughts Type(s)

Flowers

E

Color (s)

None

Reception

Wake

Other

Name of Location Street Address City, ST Zip Final Disposition Preferences

Phone (

)

—

(See Section G for Disposition Location)

Burial NO Burial Casket Preferences Wood

Fiberglass

Metal

Other

Plastic

Color / Liner Preferences: Cremation NO Cremation Container Preferences Urn

(wood, ceramic, color, etc.)

Box F Disposition Preferences Burial Vault Dispersed (Note: See Section G for specifics of location or other handling.) Donation NO Donation

Specify all or some, note your preferences Registered as an organ donor

Kidney

MVD designation

Pancreas

Eyes

Heart

Skin Grafts

Lungs

Intestinal Tissue

Permission to register on donor list Donation to Science / Education Specific school Specific program

Print Name

Signature

Date

Liver

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PERSONAL PLANNING SHEET FOR

(Name)

Final Disposition Location Desired Location (City, State) Cemetery desired Already purchased

Need to purchase

Single Plot Double Plot adjoining: Single Vault Double Vault adjoining Headstone / Marker / Monument Already purchased

G

Single

Double

Need to purchase Color / Stone type

Insignia / symbols / images Inscription Preferences

Ashes Dispersed

By Whom Location(s)

Additional Instructions & Comments Regarding Arrangements & Preferences

H

Property & Affairs

Note: This does not replace legal documents; legal documentation is strongly recommended.

Estate Trust Executor(s) or Estate Representative(s) designation

Legal document location(s)

I

Will Other Location of documents regarding disposition of personal property and effects

My Message to Loved Ones (How I hope to be remembered / My legacy / You must go on)

J

Print Name

Signature

Date

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