St. Stephen s Episcopal Church
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1 Form 1: General information for death certificate and obituary Page 1 Fill this form out on-line, or print it out and use a pen. General information for death certificate and obituary Full name Present address Birthplace Date of birth (M,D,Y) Baptismal date Baptismal place Confirmation date Confirmation place Church you are a communicant of Church address Father s full name Deceased? Birthdate Birthplace Mother s full name Deceased Birthdate Birthplace Your present status: Married Single Widowed Divorced Separated Marriage date Divorce date Date widowed Name of spouse Birthdate Birthplace Names and addresses of children Number of grandchildren Number of great-grandchildren St. Stephen s Episcopal Church
2 Form 1: General information for death certificate and obituary Page 2 Schools which you attended: Dates Dates, degree Dates, degree Dates, degree Retired? Date of retirement Retired from Present occupation if not retired Name of firm employed by: Total years in this occupation Previous ocupations Military record: Date enlisted Rank Branch of service Date & place of discharge Areas served and medals won Organizations you belong to or have belonged to: Form 1 (continued) St. Stephen s Episcopal Church
3 Form 2: Information for next of kin, page 1 My name: Date Persons to notify: Name, how related (brother, son, uncle,...) and phone number. I have made a will I have not made a will The executor of my estate is My will may be found at My attorney is Attorney s address: Attorney s phone My bank is Bank s address Bank s phone Contact person I have a safe deposit box. Location of safe deposit box key Location of insurance policies Address of insurance company Insurance company phone number Agent to contact
4 Form 2: Information for next of kin, page 2 Other important contact information: Date Signature
5 Form 3: Preferred Burial Procedures, Page 1 When a death occurs in your family, call Fr. James as soon as possible. If no one answers, please leave a message on the church answering machine and someone will get back to you as soon as possible. The most appropriate place for a Christian funeral is at the church where all important events of life are marked. A Eucharist of the Resurrection may be celebrated or the Burial Office may be said, whatever you prefer. The casket is closed during the service whether that service is held in the church or in the funeral home. A funeral pall covers the casket during the service. St. Stephen s recommends that gifts of money, in lieu of quantities of flowers, be made to charitable organizations, health funds or the Endowment Fund of St. Stephen s. UPON MY DEATH, I WISH TO HAVE THE FOLLOWING PERSONS NOTIFIED: The clergy of Church Church address: Phone: The funeral home is: Funeral home address: Phone: IF POSSIBLE, I WISH MY BURIAL SERVICE TO TAKE PLACE AT: CHURCH: Address: Phone: Conducted by: Phone: MEMORIAL SERVICE AT: Address: Phone: Conducted by: Phone: FUNERAL HOME SERVICE AT: Address: Phone: Conducted by: Phone: GRAVESIDE SERVICE AT: Address: Phone: Conducted by: Phone:
6 Form 3: Preferred Burial Procedures, Page 2 Location of cemetery plot, crypt plot or columbarium Cemetary or columbarium & phone number: Location of important items INSTRUCTION FOR THE DISPOSITION OF REMAINS I prefer to be buried I prefer to be creamated Disposal of ashes I have made arrangements for certain parts of my body to be donated to: Casket specifications: Least expensive Mid-range Elaborate [The government may provide a casket for veterans] Gravesite is: Marked Unmarked Directions for markings: Special clothing: Jewelry: Glasses: Other: Date: Signature:
7 Form 3: Preferred Burial Procedures, Page 3 I wish to have: Calling hours at the funeral home Flowers on the altar at church I wish to have contributions sent to: Church Address: Charity: Address: Charity: Address: Charity: Address: I would like to following pall bearers: INSTRUCTIONS FOR THE BURIAL OFFICE AND/OR EUCHARIST: Eucharist Rite I Rite II No opinion Burial Office Preferred time for the service Readings (chosen from the selections on pages 470,475, 480 in the Book of Common rayer): Old Testament Epistle Gospel Psalms
8 Form 3: Preferred Burial Procedures, Page 4 Hymns (chosen in consultation with priest and/or organist): Processional Hymn before Gospel Offertory Hymn Recessional Hymn Other music: I would like to following to serve as acolytes: Other Instructions for the Celebrant/Officiant: Date Signature Suggestions: Print out the final form and sign it where a signature is called for. It would be good to copy it and give it to your church to have on file and to your nearest and dearest so that it could help them get through that difficult time. Knowing what you want will help them enormously!
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