Are you filling this out for yourself or someone else?
Select My Self Someone Else Why are you choosing to pre-arrange?
Select Peace of Mind Applying for Medicaid - Spend Down Estate Elder law attorney advised to complete What urgency are you completing this form?
Select URGENT: Immediate need, a death has occurred URGENT: A death is imminent Prearranging for the future Why are you choosing to pre-arrange?
Select Peace of Mind Applying for Medicaid - Spend Down Estate Elder law attorney advised to complete
Name of Person you're Planning for First Name
Middle Name
Last Name
Address of the Person Listed Above Street Address
City
State
Zip
Birth Information Date_of_Birth
State of Birth
City of Birth
Father's complete name First Name
Middle Name
Last Name
Mother's complete name First Name
Middle Name
Last Name
Maiden Name
Education Elementary School Name
High School Name
College Name
Total Years Achieved
Degree Obtained
Employment
Main occupation During life:
Primary employer:
Industry of employment:
Additional work experience you'd like to share:
Interests, Hobbies, and Organizations Please list
Veterans Which branch?
What years of service and/or what wars?
Where was the vet stationed?
Any medals or specific memories?
What made this person smile?
What made this person feel fulfilled?
What gave them the greatest amount of pride?
What would they like to be remembered for?
What recreation/hobby did they always look forward to?
Marital Status
Marriage
Spouse or significant other's name : First
Last
Middle
Maiden name
Place of marriage : Church Name
Church City
Church State
Church & Cemetery
Church Name Where Service will be Held: Cemetery Name
Cemetery City
Cemetery State
Tell us a little of what you envision for services:
Next of Kin First
Middle
Last
Address
City
State
Phone
Zip
Email
Relationships Relationship (ex. son, daughter, wife, etc)
Please list names of surviving family members, including spouses, children, grandchildren, siblings, etc.
Who's proceeded you?
Please list names of deceased family members (including spouses, children, grandchildren, siblings, etc.)
Other Special instructions or notes for O'Connell Family Funeral Homes:
Share Email (if you'd like to send an email copy to someone or yourself, add email below)
*Please note we don't collect your Social Security number in this form but we will eventually be needing it to complete this process.
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