Pre-Arrangements Form

Personal Information

Full Name

Street

City

State/Province

ZIP/Postcode

Telephone

Date of Birth

SSN #

Email Address

Place of BirthCity/Town, State

Father's Name

Mother's Name

Mother's Maiden Name

Marital Status

Father's Place of Birth

Mother's Place of Birth

Spouse's Name

Place of Marriage

Spouse's Maiden Name(If applicable)

Date of Marriage

Additional Family MembersPlease use the area above to enter the names of siblings, children, and grandchildren.

Work/Education History

Occupation

Company Name

Business Industry

Military Record

Did you serve in the military?

YesNo

Are you interested in having Military Funeral Honors?

YesNo

Do you have a copy of your discharge papers (DD-214)?

YesNo

Branch of Service

Date Entered Service

Date Discharged

Serial Number

Rank at Discharge

Discharge on file at

Wars Fought In

Funeral Service Requests

Place of Funeral Service

Name of Service Location

Place of Visitation

Religious Denomination

Place of Worship

Lodge/Union/Association or other Membership

Disposition Request

I Prefer:

Cemetery

Lot #(if applicable)

Section/Letter(if applicable)

Grave #(if applicable)

Cemetery Address

Cemetery Telephone

I have made a last will and testament

YesNo

Location of Will

Summary Details

Person in charge of final arrangements:

Street

City

State/Province

ZIP/Postcode

Additional instructions for Holt Funeral Home

Memorial requests or donations to charity

Please select from one of the options below:

Send me information about to pre-arrangements

Contact me to set up an appointment

I am interested in pre-paying for my funeral

No appointment needed, just keep my request and information on file

Anti-Spam Security Question

Personal Information

Work/Education History

Military Record

Funeral Service Requests

Disposition Request

Summary Details

A year of daily grief support