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South Hill, VA 23970
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Bereavement
Our Location
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Free bereavement information download.

To Help You Prepare

We at Crowder-Hite-Crews realize a family cannot always remember all the needed information when a loved one dies.  Making funeral arrangements at the time of loss is extremely difficult for those left behind.

One of the most caring things you can do for your family is leave a detailed record of what you want for your funeral service.  The more complete your information is, the less difficult it will be for them.

The following form has been designed to help you write down some of this information — for yourself or a loved one, and for your funeral home.  If you choose to share this information with us, it will be kept in complete confidence and only used when needed — to prepare your obituary or other memorialization.  It may be revised at any time and is always reviewed at the time of death.

After you fill in the information, use the buttons at the end of the form to:

Send it to us now online, or
To ensure your privacy, print a copy and mail it to us; and
Print a copy to keep with your important papers.

* required
Who is completing this form?
Your Name*: E-mail Address*:
Daytime Phone: Evening Phone:
I am planning for: Best Time to
Contact:
Who is this plan for?
Full Legal Name: Title (if any):
Maiden Name
(if applicable):
Nickname:
Gender: Male   Female Social Security
Number:
Date of Birth: Place of Birth:
Citizen of what
country?
Street Address: Zip Code:
Mailing Address
(if different):
Zip Code (if
different):
City: Inside city limits? Yes   No
County: State:
Family Information
Marital Status: Year widowed
(if applicable):
Date Married: Place Married:
Spouse's Name: Spouse's
Maiden Name:
Father's Name: Father still alive? Yes   No
Mother's Name
(include Maiden):
Mother still alive? Yes   No
Education & Occupation History
Highest Grade
Completed:
Years of College
(1-4 or 5+):
Occupation: Business or
Industry:
Employer(s): Years Retired:
Professional
Organizations:
Fraternal
Memberships:
Military Record
Service Branch: Military ID (Serial
Number):
Date Enlisted: Discharge Date:
Rank Held at
Discharge:
Discharge on
File At:
Wars: Commendations
Received:
VA File (Claim #): Receiving VA
Pension?
Yes   No
Military Honors
Desired?
Yes   No Present Flag To:
Flag Drape? Yes   No
Additional Obituary Information
Notice in Papers: South Hill  Richmond  Out of Town
Papers:
Radio Station 1: Radio Station 2:
How many
children?
Grandchildren?
Great
Grandchildren?
Great Great
Grandchildren?
Survived By
Relationship Name City, State E-mail Address
Preceded in Death By
Relationship Name Relationship Name
Funeral Preferences
Private Viewing
for Family?
Yes   No Viewing for
Friends?
Yes   No
Preferred
Disposition:
Organ or body
donor?
Yes   No
Cemetery or
Crematory:
City/County
and State:
Memorial Contributions: Address / Specific Location:
For families choosing cremation, what
disposition of the cremains do you prefer?
Please provide any other funeral preferences,
special instructions or information:
Service Preferences
Service Setting: Public   Private Type of Service:
Place of Service: Name of Place:
Religious
Denomination:
Place of Worship:
Officiated By: Person's Name:
Pallbearers
Phone Number Name City, State E-mail Address
Musical Selections (if any): Performed By / Will Supply Recording:
Favorite Bible Verses / Other Readings: Reader(s) / Speaker(s):
Please list any
other service
preferences or
information:
Person in Charge of Final Arrangements
Name: Relationship:
Address: E-mail Address:
Daytime Phone: Evening Phone:
Other Information, Questions or Comments
How can we be of service?
Send information about pre-arrangement
Contact me to set an appointment
Call me to go over some questions I have
Please keep my information on file
Other (please describe in box on right)

    
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