Plan Form

 

 

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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