OnLine Pre-Planning Form

Personal Data Form

McGannHay

Funerals | Cremations | Gatherings

Mailing Address: 2313 E. Edison Rd. South Bend, IN 46615-3515

Phone: 574-232-1411 Fax: 888-855-1765

www.McGannHay.com

You may choose to complete this form, or enter only your contact information: Name, Address, Phone Number, and Email
and someone will contact you.

First Name:
Middle Name or initial:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Marital Status:
Spouse's Name:
Father's Full Name:
Mother's name incl Maidnen name:
If Jewish: Hebrew Name:
Father's Hebrew Name:
Race:
Education:
Usual Occupation/Type of Industry:
Retired:
If Yes, Date of Retirement:
If still working, number of years at place of employment:
Name of Company:
City & State:
Last Position:
Next of kin or contact person:
Address:
City:
State:
Zip Code:
Email for next of kin/contact person:
Veteran:
Location of Discharge Papers:
Would you like Military Honors:
Where would you like your service:
Clergy Person:
Place of Worship:
Final Resting Place:
Cemetery:
City & State:
Phone:
List any: Organizations, Military Srevice, Clubs, Activities, Hobbies, Points of interest for Obit:
Special Requests:
Memorial Contributions to::
Comments: