Name: First: __________________ Middle: __________________ Last: ____________________
Residence: ____________________________________________________________________
Phone: ________________________________________________________________________
Sex: ______ Race: ______ Single: ______ Married: ______ Widowed: ______ Divorced: ______
Husband of (Maiden Name): _______________________________________________________
Wife of: ________________________________________________________________________
History of Residence: _____________________________________________________________
Birthplace of Deceased - City: ______________________________________________________
Date of Birth: Month: ________ Day: _____ Year: _______
Age: ______ Months: ______ Days: _____ Years: _______
If Veteran, specify War & Company: _________________________________________________
Occupation: ______________________ Social Security: ______________________
Kind of Business: ______________________ Company: ______________________
Years Employed: ______________________ Retired: _________________________
Education Level: _______________________________________________________
Informant: ______________________________________________________________________
Phone: ________________________________________________________________________
Informant's Address: _____________________________________________________________
Father's Name: _________________________________________________________________
Father's Birthplace: ______________________________________________________________
Mother's Maiden Name: ___________________________________________________________
Mother's Birthplace: ______________________________________________________________
Cemetery/Crematory: ____________________________________________________________
City or Town: ___________________________________________________________________
Funeral at: _____________________________________________________________________
Date: __________ Hour: __________ A.M. - P.M.
Calling Hours: __________________________________________________________________
MILITARY SERVICE
Entering Date: _________________________________________________________________
Discharge Date: _______________________________________________________________
Service Number: _______________________________________________________________
Rank, Rating: __________________________________________________________________
Organization/Outfit: _____________________________________________________________
SURVIVING RELATIVES AND ADDRESSES
Father: _______________________________________________________________________
Mother: ______________________________________________________________________
Husband: ____________________________________________________________________
Wife: ________________________________________________________________________
Sons:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Daughters:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Brothers:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Sisters:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Grandchildren (No.): _____ Great Grandchildren (No.): _____
Newspapers:
___ Wellsboro Gazette___ Williamsport Sun-Gazette
___ Elmira Star-Gazette
___ Corning Leader
___ Other: _________________
___ Picture for NewspaperMemorial Donations:
_____________________________________________________________________________
_____________________________________________________________________________
SERVICE DETAILS
Clergyman: __________________________________ Call for: _________________________
Church:
_____________________________________________________________________________
_____________________________________________________________________________
Bearers:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Education:
_____________________________________________________________________________
_____________________________________________________________________________
Wedding Anniversary: ___________________________________________________________
Orders & Societies:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Music:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
CEMETERY INFORMATION
Grave No.: __________ Plot No.: ______________
Range No.: __________ Section No.: __________
Lot Owner: ___________________________________________________________________
Please return this form via mail or fax to:
WILSTON FUNERAL HOME
130 S. Main St.
Mansfield, PA 16933
Ph: 570-662-2000
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